HospitalInspections.org

Based on a review of patient #1 ' s record, it is determined that patient #1, who was restrained in 4-point bed restraints for violent behaviors while under non-violent orders, was not released at the earliest possible time during restraint events of 4/26 and 5/1/2016.
Patient #1 is an adult male in his early 30's who presented to the emergency department (ED) in the last week of April 2016 due to combative behaviors and suicidal ideation. An emergency medical screening evaluation revealed that patient #1 had an emergency medical condition. Patient #1 was certified by two physicians and admitted to treat and medically clear him for inpatient psychiatric care.

On 4/26/2016 at 2130, patient #1 became agitated and combative when attempting to leave his room in order to harm himself. Security responded and then called police. Patient #1 was restrained in 4-point restraints at approximately 2150. An incomplete written order for " 4-point hard restraint " appears in the record at 2200. This was followed by a Behavioral Restraint Order Form of 2210 with special instructions of "Remove restraint every 15 minutes from each extremity, " and lastly, a 24-hour Medical-Surgical Restraint (non-violent) Order of 2214 which while signed, indicates no specific type of restraint, and no rationale.

Based on these diverse orders, patient #1 who demonstrated behaviors per documentation warranted no more than the 4-hour violent restraints orders, was transitioned to a 24-hour non-violent order. A hospital representative verbalized their retrospective understanding that based on his behaviors, patient #1 should have continued with a violent restraint order.

A nursing note of 2300 revealed in part, " Pt carried to bed and placed in 4-point restraints per verbal order of Dr. __... Pt calm and laying in bed at this time ...Pt stating, " Just kill me " ...and, " Pt sleeping at this time ... " A sitter remained with patient #1.

A nursing note of 0338 stated in part, " Per order of Dr. __, OK to start removing restraints one at a time every 15-30 minutes. First restraint removed off of lower extremity ... " Patient #1, who had variously demonstrated calm, cooperative behaviors and had even slept, was not fully removed from restraint until 0751 of the following day, a total of approximately 9 hours.

On 5/1/2016 at approximately 0430, patient #1 came out of his room, disrobed, and walked the unit hallways while opening the doors of patient rooms and unplugging equipment he found in the hallways. He was not redirectable. When security was called, patient #1 became increasingly violent. Police were called, and patient #1 appeared to advance on an officer. He was tazed twice. A physician evaluation with EKG following the event revealed patient #1 was unharmed and medically stable.

However, at 0500, patient #1 was placed again into non-violent restraints for violent behaviors. RN notes at 0834, 1030, and 1112 respectively revealed in part, " Patient now resting calmly in bed with 1:1 sitter in room ... " Per nursing judgement, this RN unlocked and released this patient ' s right ankle from the 4 point restraints .... " And, " ...Pleasant demeanor and manners at this time, cooperating appropriately. "

At 1138, patient #1 continued in 3-point restraint, and was assessed as " calm, interactive and with good eye contact " by the RN. At 1318, patient #1 requested to use the bathroom. Security was called to escort him. On return, the RN wrote, " Left hand and ankle restraints placed back to patient. At 1319, patient #1 asked for the restraints to be taken off. The RN explained to patient #1 the need for restraint usage, but did not document what she told the patient. Patient #1's restraints were not removed until 1634, 11.5 hours following the initiation of restraint.

In summary, the hospital failed to implement appropriate restraint orders for violent behaviors which required rigorous and ongoing behavioral documentation, as well as time limitations of 4 hours. Consequently, patient #1 was restrained long after he had demonstrated he was no longer a danger to self and other, which violated his right to be free of restraint.