HospitalInspections.org

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Based on record review, interview, and review of the hospital policy and procedure, the hospital failed to ensure that patients placed in nonviolent restraints received a complete face-to-face assessment by a provider as directed by hospital policy for 3 of 6 patients in nonviolent restraints reviewed (Patients 905, #906, and #907).

Failure to perform the required face-to-face evaluation to determine whether the patient meets the specific criteria for restraint or seclusion places patients at risk of harm, injury, or other decline in status.

Findings included:

1. Document review of the hospital's policy titled, "Restraint and Seclusion Policy, 964.00," PolicyStat ID 1271679, last approved 12/22, showed the following:

a. The organization has authorized the Physician to delegate the ordering and patient evaluation for restraint use to his/or attending Certified Provider Assistants (PA) or Advanced Registered Nurse Practitioner (ARNP). Providers must have a working knowledge of the hospital restraint and seclusion policy.

b. For nonviolent restraint a new order may be issued each day after a face to face by the Provider.

2. On 05/15/24 at 9:30 AM, Investigator #9 and Nurse Educator (Staff #901) reviewed the medical record of Patient #905 who was admitted on 04/19/24 for treatment of schizoaffective disorder, bipolar type and dementia and was placed in nonviolent restraint. The review showed the following:

a. An order was placed for nonviolent restraint on 05/03/24 at 3:47 PM. A progress note was completed by a provider at 3:52 PM and showed the only mention of restraint documented as "try to wean off restraint as per protocol".

b. An order was placed for nonviolent restraint on 05/04/24 at 5:47 PM. A progress note was completed by a provider at 4:38 PM and showed the only mention of restraint documented as "try to wean off restraints per protocol".

c. An order was placed for nonviolent restraint on 05/05/24 at 4:04 PM. A progress note was completed by a provider at 4:08 PM and showed the only mention of restraint documented as "try to wean off restraints per protocol".

d. Similar findings for orders and progress notes were found on 05/06/24, 05/07/24, 05/08/24, 05/09/24, 05/10/24, 05/11/24, and 05/12/24. The patient was discharged on 05/13/24.

3. At the time of the review, Staff #901 verified the documentation of restraint in the progress notes.

4. On 05/15/24 at 10:15 AM, Investigator #9 and Nurse Educator (Staff #901) reviewed the medical record of Patient #906 who was admitted on 04/30/24 for treatment of cholecystitis (inflammation of the gall bladder commonly caused by gall stones) and was placed in nonviolent restraint on 05/05/24 at 7:12 AM. The review showed the following:

a. An order for nonviolent restraint was placed on 05/05/24 at 7:12 AM. A progress note was completed by a provider on 05/05/24 at 11:04 AM. The investigator found no mention of restraint or face to face in the note. The note showed that the patient was oriented to time, place, and person.

b. An order for nonviolent restraint was placed on 05/06/24 at 8:46 AM. A progress note was completed by a provider on 05/06/24 at 2:26 PM. The investigator found no mention of restraint or face to face in the note. The note showed that the patient was oriented to time, place, and person.

5. At the time of the review, Staff #901 verified there was no documentation regarding restraint in the provider note. The nursing documentation showed a "no" in the face to face row of the flowsheet on 05/05/24 at 7:12 AM and "yes" in the face to face row of the flowsheet on 05/06/24.

6. On 05/15/24 at 12:15 PM, Investigator #9 and Nurse Educator (Staff #901) reviewed the medical record of Patient #907 who was admitted on 05/10/24 for treatment of respiratory failure and placed in nonviolent restraint on 05/10/24 at 10:00 AM. The review showed the following:

a. An order for nonviolent restraint was placed by a provider on 05/10/24 at 11:00 AM. A history and physical was completed and filed by a provider on 05/10/24 at 11:39 AM. The investigator found no mention of restraint or face to face in the note.

b. An order for nonviolent restraint was placed on 05/11/24 at 10:53 AM. A progress note was completed by a provider on 05/11/24 at 11:03 AM. The investigator found no mention of restraint or face to face in the note.

7. At the time of the review, Staff #901 verified there was no documentation regarding restraint in the provider notes.
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Based on record review, interview, and review of the hospital policy and procedure, the hospital failed to ensure that patients placed in violent restraints received a complete face-to-face assessment by a provider as directed by hospital policy for 4 of 6 patients in violent restraints reviewed (Patients #901, #902, #903, and #904).

Failure to perform the required face-to-face evaluation to determine whether the patient meets the specific criteria for restraint or seclusion places patients at risk of harm, injury, or other decline in status.

Findings included:

1. Document review of the hospital's policy titled, "Restraint and Seclusion Policy, 964.00," PolicyStat ID 1271679, last approved 12/22, showed the following:

a. The organization has authorized the Physician to delegate the ordering and patient evaluation for restraint use to his/or attending Certified Provider Assistants (PA) or Advanced Registered Nurse Practitioner (ARNP). Providers must have a working knowledge of the hospital restraint and seclusion policy.

b. For violent restraint use, a one hour face to face evaluation by the provider to include: patient's immediate situation, patient's reaction to the intervention, patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion is required.

2. On 05/16/24 between 2:00 PM and 3:00 PM, Investigator #9 and Emergency Department Manager (Staff #902), Chief Nursing Officer (Staff #903), Chief Medical Officer (Staff #904), Chief Operating Officer (Staff #905) and Regulatory Manager (Staff #906) reviewed the medical records of patient's placed in violent restraint. The review showed the following:

a. Patient #901 presented to the Emergency Department for Psychotic Disorder and hallucinations. The patient was placed in violent restraint on 05/13/24 at 10:13 PM. The Investigator found no evidence a provider documented a complete face-to-face assessment.

b. Patient #902 presented to the Emergency Department for Psychosis and substance use. The patient was placed in violent restraint on 05/09/24 at 5:54 AM. The Investigator found no evidence a provider documented a complete face-to-face assessment.

c. Patient #903 presented to the Emergency Department for agitated and aggressive behavior after a drug overdose. The patient was placed in violent restraint on 05/04/24 at 12:51 AM. The Investigator found no evidence a provider documented a complete face-to-face assessment.

d. Patient #904 presented to the Emergency Department for altered mental status and drug overdose. The patient was placed in violent restraint at 6:53 PM. The Investigator found no evidence a provider documented a complete face-to-face assessment.

3. At the time of the review, Staff #902 verified that they did not see all 4 elements of the face to face in the provider documentation.

4. Investigator #9 interviewed an Emergency Department physician (Staff #908) regarding process for completing face to face documentation in the Emergency Department. Staff #908 stated that they understood the only documentation required for the face to face was the order.
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