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Based on Policy and Procedure review, Medical Record review, and Staff and Physician interviews, the staff failed to recognize a physical hold as a restraint and obtain a physician order for restraint for 1 of 3 patient's restrained (Pt # 2)
The findings include:
Review of Policy and Clinical Practice Guidelines, "RESTRICTIVE INTERVENTIONS", reviewed/revised 08/2013, revealed "The leadership of the organization recognizes that all patients have the right to respectful care with consideration for their rights, dignity, and safety at all times. Restraint is only utilized when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member or others from harm....I. POLICY....The use of restraint is in accordance with the order of a physician or other licensed independent practitioner who is responsible for the care of the patient, has a working knowledge of hospital policy regarding the use of restraint and seclusion and is authorized to order restraint by hospital policy....II. DEFINITION AND EXCEPTIONS A. A restraint is any manual method, physical or mechanical device....that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely....1. A restraint does not include devices such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting physical examinations or tests....C. the management of violent and self-destructive behavior can occur as a part of medical and surgical care as well as part of psychiatric care. The use of language 'violent and self-destructive behavior' is intended to clarify the application of these requirements across all patient populations. 1. Violent/self-destructive restraint utilization applies to severely aggressive, violent or destructive behavior that presents an immediate, serious danger to the safety of the patient, staff members, or others and requires rapid assessment and intervention. ..." Further review of the Policy and Clinical Practice Guidelines failed to reveal other documentation or definitions related specifically to physical holds.
Closed medical record review on 04/15/2015 of Pt # 2 revealed the patient was brought to the Emergency Department (ED) by ambulance on 10/21/2014 at 2016. Review of the ED Triage note, dated 10/21/2014 at 2030 revealed "...Pt (Patient) BIB (brought in by) EMS (Emergency Medical Services) for SI (Suicidal Ideation). Pt shot father in shoulder with BB gun then ran into the woods. Pt told police to shoot him. Police called medic for transport. ..." Review of Nursing Documentation revealed a Psychosocial Assessment stating the Patient was a suicide risk, "Pt states he wanted to shoot himself & (and) would do so again when he leaves. ..." Record review revealed an Involuntary Commitment form stating the patient was examined 10/21/2014 at 2110 and found to be mentally ill, with "...Impression/Diagnosis: Suicidal Ideation". Review of ED Physician Documentation revealed "...Before the patient was completely triaged he attempted to leave the facility and was restrained by security. During this process he was struck in the face and had bleeding from his nose and a laceration under his eye....He was very agitated... ." Review of the medical record revealed no order for a restraint for a physical hold.
Review of Hospital Document, Security Report revealed "...On October 21, 2014....At approximately 2029 (names of Officers # 1 and # 2) received a call....of a panic alarm button activation for the 1st floor Emergency room nurses desk. Upon arrival at the nurses desk double doors, (Officer # 1) observed Registered Nurse (RN) # 1 attempting to direct (Pt # 2) back to his bed. (RN # 1) then informed (Pt # 2)....why he couldn't leave the unit, and also advised him that he would be escorted to his bed by (Officer # 1). (Pt # 2) immediately stated that he was leaving....(Pt # 2) then attempted to walk pass (Officer # 1) to exit the ED double doors and was immediately detain(ed) with minimal force....(Pt # 2) then took a swing at (Officer # 1) face. (Officer # 1) was able to avoid the strike. (Officer # 1) then attempted to gained control of (Pt # 2) and was able to take him to the ground using the least amount of force necessary to stop the aggression. At approximately 2035 hours, (RN # 1) informed (Officer # 1) that she (was) contacting the (name of City Police Department) to respond to assist. (Hospital Officer # 2) arrived on scene to assist in restraining (Pt # 2). (Pt # 2) continued to act aggressive by making threatening comments towards (Officer # 2). (RN # 1) advised (Officer # 1) and (Officer # 2) to escort (Pt # 2) back to hallway bed 3 for possible 4 point soft restraints upon (MD # 1) authorization. (Pt # 2) was then instructed by (Officer # 2) that he be assisted off the floor on his feet by security and escorted to his bed. Once on his feet (Pt # 2) took a swing at (Officer # 2), making contact with his face. (Officer # 1) and (Officer # 2) immediately attempted to regain control of (Pt # 2) and he fell against the ED Minor chairs, causing minor injury to his nose. ..."
Interview on 04/15/2015 at 1530 with Officer # 1 revealed that he received a message to go the ED, that a panic button in the ED had been activated. Interview revealed that as he reached the ED doorway, he heard RN # 1 tell Pt # 2 he could not leave "pending assessment". The patient was standing facing the RN. Interview revealed Officer # 1 told Pt # 2 he would assist the patient back to bed. The patient stated "I'm not afraid of you. I've been in the Army and know how to defend myself. If you touch me there is going to be a fight." Interview revealed Officer # 1 said "Sir, I don't want to fight you. You cannot leave until you've been seen by the doctor. ..." Interview then revealed "he started walking toward the right side to leave. I moved over to block his way. His left arm was in a sling. I said 'Sir, I will show you how to get back to bed. ..." Interview revealed Officer # 1 gently put his hand on Pt # 2's left shoulder and turned him around then took his hand off the shoulder. Interview revealed Pt # 2 did not resist and they began to walk. Interview revealed Pt # 2 and Officer # 1 took three to four steps when Pt # 2 took a swing with his right arm toward Officer # 1's face. Officer # 1 stated he blocked the punch with a CPI (Crisis Prevention Intervention) technique in which he raised his arm to deflect the punch. Interview revealed Pt # 2 threw another punch and this time Officer # 1 used a different technique, where two hands are placed on the patient's arm and the shoulder is twisted. Interview revealed Pt # 2 resisted by backing up and trying to get loose and both Officer and Pt went to the floor. Interview revealed Pt # 2 said "let me go" and Officer # 1 said "Sir, you cannot leave pending assessment." Further interview revealed Officer # 2 arrived and put his hands on the patient's arms and Officer # 1 got up. Officer # 2, interview revealed, then told Pt # 2 "we are going to get you up, walk you back to bed, and you are not going to be hitting people." Interview revealed the officers assisted him up. Now, interview revealed, Pt # 2 was standing facing the officers and he swung and hit Officer # 2 across the face and both officers tried to gain control. Interview revealed Officer # 1 put his hand on Pt # 2's left shoulder and Officer # 2 had his hand on the patient's right arm. Pt # 2 started to try and back away and the officers tried to maintain control. The momentum of their "trying to hold him" carried them to the doorway towards Minor Care, and Officer # 1 fell backwards on the floor and Officer # 2 and Pt # 2 fell onto the chairs on the left side of the hall. Interview revealed Officer # 1 got up and Pt # 2 was on the chair. Interview revealed the officers "pretty much had him restrained because he was on a chair." Interview revealed the officers were holding Pt # 2's arms and hands and got the Pt standing, then they helped him up and he did not resist. Interview revealed other staff members brought a bed to the area, Pt # 2 sat himself on the bed and the doctor talked to him. Further interview revealed Officer # 1 did not think that what happened would be considered a restraint.
Interview with Security Manager # 1 revealed the staff receives "scenario based training" and learn that it is okay to put a hand on to redirect a patient, but you do not want to use force. When asked if this was a restraint, Security Manager # 1 stated they did not consider it a restraint.
Interview with Administrative Staff (AS) # 1 on 04/15/2015 at 1525 revealed she was a supervisor and was on duty at the time of the event with Pt # 2. Interivew revealed she was called "after the fact" and did not go to the area at that time so she had no first hand knowledge of the event. Interview revealed she would have gone if notified of a restraint.
Telephone Interview with MD # 1 on 04/15/2015 at 1425 revealed Pt # 2 was brought into the ED from being out in the woods where he said he was going to shoot himself. MD # 1 stated Pt # 2 was "placed in the hallway where we can keep an eye on him. One of the nurses came and said he was trying to leave". When MD # 1 got to the patient, interview revealed, the incident had already occurred and Pt # 1 was very adament he wanted to leave. MD # 1 stated she tried to get him back into a room and deescalate the situation. Two security guards had a hold on him "physically restraining him from leaving". Interview revealed the only physical restraint was at the time Pt # 2 was "walking out the door....He came in because he was suicidal, we can't let him leave". Interview confirmed there was no order for a restraint and when asked if a hold that detains a patient is a restraint, interview revealed "...I consider a restraint a prolonged situation."
Interview with AS # 3 on 04/16/2015 at 1625 revealed the event was viewed as a security event, not a physical hold/ restraint. Interview confirmed there was no order for restraint.

Based on Policy and Procedure review, Medical Record review, and staff and physician interviews the staff failed to provide ongoing assessments and monitoring of the condition of a patient during a restraint for 1 of 3 patients restrained. (Pt # 2)
The findings include:
Review of Policy and Clinical Practice Guidelines, "RESTRICTIVE INTERVENTIONS", reviewed/revised 08/2013, revealed "The leadership of the organization recognizes that all patients have the right to respectful care with consideration for their rights, dignity, and safety at all times. Restraint is only utilized when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member or others from harm....II. DEFINITION AND EXCEPTIONS A. A restraint is any manual method, physical or mechanical device....that immobilizes or reduces the ability of a patient to move his or her arms, legs, body or head freely....1. A restraint does not include devices such as orthopedically prescribed devices, surgical dressings or bandages, protective helmets, or other methods that involve the physical holding of a patient for the purpose of conducting physical examinations or tests....C. the management of violent and self-destructive behavior can occur as a part of medical and surgical care as well as part of psychiatric care. The use of language 'violent and self-destructive behavior' is intended to clarify the application of these requirements across all patient populations. 1. Violent/self-destructive restraint utilization applies to severely aggressive, violent or destructive behavior that presents an immediate, serious danger to the safety of the patient, staff members, or others and requires rapid assessment and intervention....VII. INTERVENTION G. Assessment/monitoring/patient care: violent self destructive restrictive intervention utilization 1. Assess and document at initiation and every 15 minutes: a. Respiratory quality and/or rate b. Restrictive interventions device in use c. Readiness for discontinuation of restraint/seclusion d. Safety and circulation adequate e. Less restrictive methods or alternatives f. Meets criteria to continue restrictive interventions. ..." Review of the Policy and Clinical Practice Guidelines failed to reveal any other definitions or requirements related to physical holds.
Closed medical record review on 04/15/2015 of Pt # 2's record revealed he was brought to the Emergency Department (ED) by ambulance on 10/21/2014 at 2016. Review of the ED Triage note, dated 10/21/2014 at 2030 revealed "...Pt (Patient) BIB (brought in by) EMS (Emergency Medical Services) for SI (Suicidal Ideation). Pt shot father in shoulder with BB gun then ran into the woods. Pt told police to shoot him. Police called medic for transport. ..." Review of Nursing Documentation revealed a Psychosocial Assessment stating the Patient was a suicide risk, "Pt states he wanted to shoot himself & (and) would do so again when he leaves. ..." Record review revealed an Involuntary Commitment form stating the patient was examined 10/21/2014 at 2110 and found to be mentally ill, with "...Impression/Diagnosis: Suicidal Ideation". Review of ED Physician Documentation revealed "...Before the patient was completely triaged he attempted to leave the facility and was restrained by security. During this process he was struck in the face and had bleeding from his nose and a laceration under his eye....He was very agitated... ." Record review revealed documention of nursing assessment after the event, including on 10/21/2014 at 2140 "...Laceration....below rt (right) eye".Record review did not reveal documentation of assessment or monitoring by a nurse during the restraint.
Review of Hospital Document, Security Report revealed "...On October 21, 2014....At approximately 2029 (names of Officers # 1 and # 2) received a call....of a panic alarm button activation for the 1st floor Emergency room nurses desk. Upon arrival at the nurses desk double doors, (Officer # 1) observed Registered Nurse (RN) # 1 attempting to direct (Pt # 2) back to his bed. (RN # 1) then informed (Pt # 2)....why he couldn't leave the unit, and also advised him that he would be escorted to his bed by (Officer # 1). (Pt # 2) immediately stated that he was leaving....(Pt # 2) then attempted to walk pass (Officer # 1) to exit the ED double doors and was immediately detained with minimal force....(Pt # 2) then took a swing at (Officer # 1) face. (Officer # 1) was able to avoid he strike. (Officer # 1) then attempted to gained control of (Pt # 2) and was able to take him to the ground using the least amount of force necessary to stop the aggression....Officer # 2) arrived on scene to assist in restraining (Pt # 2). (Pt # 2) continued to act aggressive by making threatening comments towards (Officer # 2)....(Pt # 2) was then instructed by (Officer # 2) that he be assisted off the floor on his feet by security and escorted to his bed. Once on his feet (Pt # 2) took a swing at (Officer # 2), making contact with his face. (Officer # 1) and (Officer # 2) immediately attempted to regain control of (Pt # 2) and he fell against the ED Minor chairs, causing minor injury to his nose. At approximately 2045 (16 minutes after the panic button notification and 10 minutes after Officer # 1 and Pt # 2 went to the floor) (MD # 1) and ED staff members arrived on the scene with a stretcher... ."
Interview on 04/15/2015 at 1530 with Officer # 1 revealed that as he reached the ED doorway, he heard RN # 1 tell Pt # 2 he could not leave "pending assessment". The patient was standing facing the RN. Interview revealed Officer # 1 went in and told Pt # 2 he would assist the patient back to bed. Pt # 2 "started walking toward the right side to leave. I moved over to block his way. His left arm was in a sling. I said 'Sir, I will show you how to get back to bed. ..." Interview revealed Officer # 1 put his hand on Pt # 2's left shoulder without force and turned the Pt around and then took his hand off the shoulder. Interview revealed Pt # 2 did not resist and they began to walk. After about three to four steps Pt # 2 swung with his right arm toward Officer # 1's face. Officer # 1 stated he blocked the punch with a CPI (Crisis Prevention Intervention) technique. Interview revealed Pt # 2 threw another punch and this time Officer # 1 used a different technique, where one hand is placed above the wrist and the other under the arm and the shoulder is twisted. Interview revealed Pt # 2 resisted by backing up and trying to get loose and both Officer and Pt went to the floor. Interview revealed Pt # 2 said "let me go" and Officer # 1 said "Sir, you cannot leave pending assessment." Further interview revealed Officer # 2 arrived and put his hands on the patient's arms and Officer # 1 got up, then the two officers assisted teh Patient to get up. Then, interview revealed, Pt # 2 swung and hit Officer # 2 across the face and both officers tried to gain control. Interview revealed Officer # 1 put his hand on Pt # 2's left shoulder and Officer # 2 had his hand on the patient's right arm. Pt # 2 started to try and back away and the officers tried to maintain control. The momentum of their "trying to hold him" carried them towards the doorway near Minor Care, and Officer # 1 fell backwards on the floor and Officer # 2 and Pt # 2 fell onto the chairs on the left side of the hall. Interview revealed the officers were holding Pt # 2's arms and hands and "we got him standing. We helped him up. He was not resisting. ..." Interview revealed other staff members brought a bed to the area and Pt # 2 sat himself on the bed and the doctor was talking to him. ..." Further interview revealed that Officer # 1 did not think that what happened would be considered a restraint.
Interview with RN # 1 on 04/15/2015 at 1500 revealed Pt # 2 was in a hallway bed and "started threatening he was going to leave. He couldn't leave...(Pt # 2) threatened that if anyone touched him he would do bodily harm. ..." Interview revealed an ED panic button was pushed and Officer # 1 responded. RN # 1 and Officer # 1 were talking with the Patient, and at "some point he (Pt # 2) and (Officer # 1) scuffled and went to the floor." Once this happened, interview revealed, RN # 1 called the City Police Department because Pt # 2 was violent and was not in control. The second Hospital Security Officer (Officer # 2) arrived and got Pt # 2 on his feet and both officers walked with Pt # 2 towards the minor care area in the ED. Interview revealed that since the officers were walking with the patient, RN # 1 "went around the corner" and then heard another scuffle. "I could not see the patient or the officers....I didn't see the second scuffle, I don't know what happened."
Interview with RN # 2 on 04/16/2015 at 1145 revealed Pt # 2 was taken straight to a hallway bed to get evaluated and RN # 2 went to help with the patient's triage. She got vital signs and began asking the routine questions when the patient decided to get up and walk down the main hallway towards an exit. Interview revealed she got RN # 1 to help with the situation and security was called. Interview revealed RN # 2 then went back to the Nurses Desk to put the triage data into the computer; she left because RN # 1 was there. Interview revealed RN # 2 did not see anything that happened.
Telephone interview with RN # 3 on 04/16/2015 at 1210 revealed that he became the patient's nurse after the event. Interview revealed he did not work with the patient before the event and did not see the event.
Interviews failed to reveal a nurse or other clinical staff who witnessed the event or monitored the patient during the event.
Interview with AS # 3 on 04/16/2015 at 1625 revealed the hands on was viewed as a security event, not a physical hold / restraint. Interview confirmed no nurse witnessed what happened and no nurse was monitoring the patient at the time.
NC0010543, NC00105122, NC00096903, NC00100936, NC00101484, NC00101663, NC00103178, NC00104395 and NC00105362