HospitalInspections.org

Based on a review of the "Emergency Department Policy & Procedure Manual" (EDPPM) (April 2017), patient #3's restraint record, and training for "Behavioral Health Patients and Restraints Usage in the ED" (BHPRUED), it was revealed that the hospital 1) failed to assess the need for restraint for P3 who was not under arrest, but who remained in police handcuffs for approximately 3 hours after presentation; and 2) coerced patient #3 when the hospital medicated and mechanically restrained patient #3 for the purpose of obtaining blood and urine against P3's expressed refusal.

Review of the EDPPM revealed in part, "Situations not considered restraint include: "Forensic and correction restrictions used for Law Enforcement (handcuffs)." This policy element failed to differentiate between patients who were under arrest and in the ongoing custody of police, versus those patients for whom handcuffs were used for transport only until responsibility was transferred to ED clinicians.

Patient #3 (P3) presented via police to the emergency department in September 2018 at 0117. P3 was on an Emergency Petition (EP) for evaluation of being a danger to self or other following P3's social media posting of potential self-harm. P3 presented in police handcuffs.

A patient on EP is not under arrest but is transferred to a hospital for an evaluation of the need for involuntary admission. An evaluation of dangerousness to self or other and the need for involuntary psychiatric admission does not require any physically invasive procedures in non-emergency situations. Further, patients on EP retain their right to refuse invasive procedures.

Hospital training for "Behavioral Health Patients and Restraint Usage in the ED" revealed in part, "All BH patients have the right to refuse procedures and medications unless they have been deemed incompetent to make their own decisions per hospital policy."
A nursing note of 0230 revealed in part, "Pt ambulated to ER room 24 with police with steady gait without issue. Pt in handcuffs by police. Pt refusing to cooperate. Pt refused urine and bloodwork ...Pt states, 'I don't care if this is a long process' ..." A nursing note of 0254 revealed in part, Pt remains in police handcuffs.

A nursing note of 0420 stated in part, "MD__ to the bedside to discuss blood draw with pt. Pt continue to refuse. Pt making verbal threats to staff members if they attempt blood draw. Pt appears under the influence of unknown substance and is acting altered. MD states physical restraint necessary to obtain labs at this time due to altered mental status. Security at the bedside. Officers at the bedside. Pt placed in 4-point restraint at this time ..." An amendment at 0509 read, "Police officers removed handcuffs prior to restraint placement." The order for restraint revealed a rationale of ""Threatening violence if getting a lab draw." P3 was also given intramuscular medications with a rationale of "Refusing Medical Evaluation of AMS" (altered mental status). P3's blood was taken under restraint at that time against P3's will.

A nursing note of 0428 revealed in part, "4 point restraints removed by security at this time. Pt remains stable ..." P3 was restrained for the purpose of obtaining a blood sample that P3 had expressly refused to give. While the hospital cited an alteration in mental status, no documentation of a material change in mental status from baseline indicated the need for an emergently drawn blood sample against P3's refusal nor was a an evaluation of capacity performed. No content of the "threat" to staff was documented, nor would a threat negate P3's right to refuse blood draw.

At 0950, and 1007 P3 was made aware by nursing that a urine sample was needed. P3 responded, "Well I just sit here all day instead." At 1202, P3 ambulated to the bathroom and stated in part, "I will go to the bathroom whenever I ... please."
At 1146, a physician wrote an order for "Straight cath for urine spec." This meant that the physician ordered nursing to insert a catheter into P3's urethra and bladder to obtain a urine specimen.

An additional order for restraint was placed at the same time with a rationale of "invol (involuntary) refusing care, aggressive. Though P3 was certified for involuntary admission, P3 retained the right to refuse "care," which in this case represented the need to obtain a urine sample. Additionally, more intramuscular medication was given to P3.

At 1220, per a nursing note, "Pt placed in restraints per order at this time for continued uncooperation [sic] with staff, pt had to be guided out of bathroom by security, as pt refused to come out willing. Pt had verbal altercation with RN prior to restraint placement. Pt attempted to slam RM 24 door in this RN's face while this RN was attempting to again explain POC (plan of care) with pt and the need for urine and cooperation. During altercation pt yelling "leave me the __ alone, you can't tell me what the __ to do!" ...Pt continued to be aggressive and boisterous prior to restraint placement ..." While P3 was in restraints, urine was obtained by straight catheterization at 1224 against P3's expressed refusal. P3 was released from restraint by 1303 as P3 slept.

In summary, the hospital failed to assess P3 for the need of hospital restraints prior to the ongoing use of police handcuffs for 3 hours. The staff further failed to honor P3's right to refuse procedures when they restrained P3 for the purpose of obtaining blood and urine against P3's expressed refusal.

Based on a review of 10 medical records and policies and procedures during the survey on 10/23/18, it was determined that the hospital left one patient (P3) in forensic handcuffs without clinical oversight even after the hospital had taken responsibility for the patient. In addition, the emergency department's (ED) restraint policy did not require that staff perform a clinical assessment of the need for restraint and whether patients not under arrest may be removed from forensic restraints.

Patient #3 (P3) presented via police to the emergency department in September 2018 at 0117. P3 was on an Emergency Petition (EP) for evaluation of being a danger to self or other following P3's social media posting of potential self-harm. P3 presented in police handcuffs.

According to the ED restraint policy, ED clinicians were not required to monitor the safety of patients in handcuffs in the ED even when the patient was fully the responsibility of the hospital. Additionally, there was no expectation in policy for clinicians to perform a clinical assessment of the need to apply and continue restraints.

Following P3's presentation, and even though the clinical staff had started their assessment, the hospital failed to perform an independent assessment of dangerousness and failed be accountable for the fact that P3, who was not under police arrest, remained in police handcuffs for approximately 3 hours. Notwithstanding the police presence, if clinicians determined that there was justification for restraint, they were obligated to transfer P3 into hospital approved restraints. No such assessment occurred, and per EDPPM policy, no such assessment was required.

Based on a review of the hospital use of force policy (UOF), the Emergency Department Policy & Procedure Manual (EDPPM), and hospital expectations and oversight of contracted off-duty police officer (HCODPO), it was determined that the hospital 1) failed to include a requirement for clinical oversight in the UOF; and 2) failed to have an expectation of training and oversight for the HCODPO officer.

Review of the hospital UOF policy revealed in part, " ...4. All physical interventions involving patients will be done in accordance with approved (Restraint/Seclusion) (R/S) techniques as taught by a certified (R/S) Instructor." No policy element revealed a requirement for clinical oversight during physical interventions involving patients.

Interview with a Security Staff on October 23, 2018 at approximately 1030 revealed that in addition to security staff, the hospital contracted town police officers for additional security services. Further, that the police officers carried "all equipment one would expect police to carry." A request for more information from Administrative staff revealed a contract with the town for the use of police services.

A contract dated 9/2017 between the town and the hospital revealed in part, that "The officer shall not be under the direct control of the Property Owner (hospital). On inquiry for a job description, a job description which originated from the town on the day of survey, and which was not previously a part of the officer file, stated in part:

"1. Assist hospital security staff with any incidents when requested or needed.
2. Assist hospital staff with uncooperative psychiatric patients
3. Assist police and sheriff personnel/corrections officers with uncooperative prisoners transported for medical treatment."

Further inquiry revealed that police officers did not receive the approved hospital training prior to putting hands on patients. The officer could be called to help with an uncooperative psychiatric patient, or in any other instance, without clinical oversight of patient safety and without using an approved and safe hospital restraint process.