HospitalInspections.org

Based on the review of clinical records for 5 (five) patients for whom restraints were used, and staff interviews, the facility staff failed to ensure that restraint orders were obtained immediately, within a few minutes, after the restraint of 1 (one) patient (Patient #6), that the physician orders for emergency safety intervention were consistent with procedures documented by facility staff for one patient (Patient #6), and that physician orders were authenticated for one patient (Patient #7).

Findings include:

1. Documentation from 2/11/2016 at 0345 (3:45 AM) was that a physical hold was initiated for Patient #6 at 0300 (3:00 AM), was discontinued at 0305 (3:05 AM), and that the attending physician was not notified because "Multiple attempts made to notify attending physician (physician's name), but were unsuccessful. (Physician's name) was notified and a restraint order obtained after 1 (one) hour". "(Physician's name) notified at 0410 (4:10 AM)".
Staff Member #1 stated the following regarding the above findings at 3:20 PM on 9/28/16: "There is no order for restraint. We knew there wasn't one on there, because (the nurse) talked to (physician's name)."
The supervisor's report dated 2/11/16 documents "Attempted to call (physician's name) to get order x 1 hr without success. Contacted (name of Staff Member #4 (four)), AOC (Administrator on call), and then received order from (physician's name) at 0410 (4:10 AM). At 0630 (6:30 AM) we have not heard from (physician's name). Incident report completed".

2. The surveyor noted a physician telephone order in Patient #6's record dated 2/7/16 at 1320 (1:20 PM) for a physical hold for up to 2 (two) hours for aggressive behavior; however, the record lacked documentation of a hold at 1320 on 2/7/16 in the nurses notes. There was documentation by the nurse related to a physical hold, soft restraints x 4 (four) and seclusion beginning at 0125 (1:25 AM) on 2/7/16.
The supervisor's report dated 2/7/16 documented "(Patient's name) required IM/hold/locked seclusion at 0125 (1:25 AM)-assaulting staff. Unit had some difficulty contacting (physician's name) between 2330 (11:30 PM) and 0150 (1:50 AM) but he did eventually call back and gave orders for additional meds".
In an interview on 9/28/16 at 2:55 PM, Staff Member #1 stated "the nurse did not use military time, but that is the order that goes with that documentation, that nurse no longer works here".
Documentation by the nurse in the restraint monitor section of the EMR (electronic medical record) was that restraint was applied at 0125 (1:25 AM) on 2/7/16, restraints used were "soft x's 4, physical holding, seclusion"; "restraint discontinued at 0515 (5:15 AM)".
The restraint/seclusion narrative note dated 2/7/16 at 0527 (5:27 AM) documented 2 physical holds on 2/7/16 (#1 and #2); documentation in the Patient Notes was that #1 began at 0125 (1:25 AM) and ended at 0127 (1:27 AM); #2 began at 0211 (2:11 AM), and ended at 0213 (2:13 AM).
A mechanical restraint is documented in the narrative note with a begin time of 0322 (3:22 AM) and end time of 0515 (5:15 AM).
There is documentation in the narrative note of 3 (three) episodes of seclusion on 2/7/16 ( #1,2,3). #1 episode of seclusion was documented as beginning at 0127 (1:27 AM) and ending at 0210 (2:10 AM); #2 episode of seclusion was documented beginning at 0213 (2:13 AM) and ending at 0230 (2:30 AM); #3 episode of seclusion was documented as beginning at 0235 (2:35 AM) and ending at 0320 (3:20 AM).
There was no documentation in the narrative nursing note of a restraint after the seclusion ended at 0320 (3:20 AM); however, the restraint monitor documentation is that restraints were applied on 2/7/26 at 0125 (1:25 AM) and discontinued on 2/7/16 at 0515 (5:15 AM).
The Seclusion/Restraints observation check sheet documentation between 0125 (1:25 AM) and 0515 (5:15 AM) does not include a code for mechanical restraint, which is inconsistent with narrative nurses note.
The Seclusion/Restraint observation check sheet documented physical holds at 0125 (1:25 AM), 0211 (2:11 AM), and at 0320 (3:20 AM) in conjunction with seclusion. Circulation checks are documented at 0210 (2:10 AM), and ROM (range of motion) at 0320 (3:20 AM).
The Seclusion/Restraint observation check sheet documents seclusion off and on between 0127 (1:27 AM) and 0250 (2:50 AM). Seclusion is then documented every 5 (five) minutes continuously between 0255 (2:55 AM) and 0515 (5:15 AM) (total of 2 hours 20 minutes).
Physician orders for restraint which were in the medical record and available for the surveyor to review for 2/7/16 included:
(#1) date: 2/7/16, time: 1320 (1:20 PM) T.O. (telephone order) (physician's name) (nurse's name) RBV (read back verbal order) 1. Give Zyprexa 5 (five) mg (milligrams) IM (intramuscular) for agitation Q6 (six) hrs (every 6 hours) PRN (as needed), may start at 2:00 AM on 2/7/16. 2. Give benedryl {sic}50 mg IM for agitation PRN Q6 hrs, may start at 2:00 AM on 2/7/16. 3. "Special treatment orders" Place pt. (patient) in hold up to 2 hour(s), STAT (immediately), for aggressive behavior. To be re-evaluated every 2 hours, up 24 hours per hospital policy. Discontinue restrictive intervention when pt. is able remain calm, no longer aggressive to staff and no longer destroying property.
In an interview on 9/28/16 at 2:55 PM, Staff Member #1 stated "the nurse did not use military time, but that is the order that goes with that documentation, that nurse no longer works here".
(#2) date: 2/7/16; time: 0320 (3:20 AM) T.O. (physician's name) (nurse's name) RBV "Special treatment procedure Place pt. in hold up to 2 hour(s), STAT (immediately), for aggressive behavior. To be re-evaluated every 2 hours, up 24 hours per hospital policy. Discontinue restrictive intervention when pt. is able remain calm, no longer aggressive to staff and no longer destroying property. 2. May give Zyprexa 2.5 mg IM for agitation one time at 6:30 AM if pt remains aggressive or self injurious.
There were no orders for seclusion or mechanical holds available for review in the EMR for Patient #6 for the above episodes of restraint which had been documented for 2/7/16. Documentation on the Seclusion/Restraints observation check sheet, the restraint monitor, and the narrative nursing notes was not consistent.
On 9/28/2016 at 2:55 PM Staff Member #1 told the surveyor that "(nurse's name) must have included all restraints in this order instead of getting orders for each; the order doesn't match the event. The order is for a hold, but event was seclusion. We were aware that there were problems with this record in February. That nurse no longer works here".

3. Nursing notes in Patient #6's EMR for 2/17/16 documented the following regarding physical holds, mechanical restraint, and locked seclusion of Patient #6 on that date:
A. A physical hold for Patient #6 was initiated at 1800 (6:00 PM), and was discontinued at 1815 (6:15 PM). A second physical hold for Patient #6 was documented between 2145 (9:45 PM) and 2150 (9:50 PM).
B. Patient #6 was placed into locked seclusion between 2151 (9:51 PM) and 2229 (10:29 PM).
C. Patient #6 was placed in a mechanical hold from 2230 (10:30 PM) until 2300 (11:00 PM).
Facility staff uses a "Special treatment procedure" stamp for restrictive intervention orders for a verbal physician order for restraint.
The stamps have blanks so that the nurse may fill in the type of restraint, how long the intervention is to last, the unsafe behavior requiring restraint, and criteria as to when a patient may be released from the emergency safety intervention.
The "Special treatment procedure" stamp corresponding to the safety interventions order for Patient #6 was dated 2/24/16 at 1845 (6:45 PM) as a "Late entry for 2/17/16, and included the following information:
Physical restraint up to 2 hours, STAT for being a danger to self and others. To be re-evaluated every 2 hours, up to 24 hours per hospital policy. Discontinue restrictive intervention when pt. is able to no longer danger to self and others". The order was was signed by the physician on 2/25/16 at 8:50 AM. There were no physician orders for locked seclusion or mechanical restraint found in Patient #6's EMR.
The Seclusion/Restraints observation check sheet dated 2/17/16, time in 21:45 (9:45 PM), time out 23:00 (11:00 PM) includes documentation that at 9:45 PM Patient #6 was in a physical hold; at 10:00 PM he/she was placed into seclusion, medication was administered, and he/she was threatening; at 10:15 PM Patient #6 was in seclusion and threatening. At 10:30 PM and 10:45 PM it was documented that Patient #6 was in 4 point restraints, threatening, and at 11:00 PM, 4 point restraints were discontinued. There were no staff initials documented beside the codes written in on the check sheet.
The documentation in the nursing notes for 2/17/16 does not correspond with the documentation on the Seclusion/Restraint observation check sheet.
The supervisor's note dated 2/17/16 documented the following: "Code BERT called x 2 due to behavior (destructive/threatening). IM (intramuscular) Zyprexa, Benadryl given, restraint bed to prevent harm. IM Ativan. Unable to reach (physician's name) for 1/2 (half) hour tonight".
Code BERT is a team of staff assigned to respond to behavioral issues within the hospital.

4. During an interview with Staff Member #4, the Assistant Administrator, on 9/29/16 at 2:00 PM regarding restraint orders obtained more than one hour after the ESI (emergency safety intervention) was initiated and missing ESI orders, he/she stated "We recognized that this was a problem, we just spoke to staff about this. We did a review of restraints to see if there was a problem. There was a period where we had a couple of misses, we are aware of that".

5. While interviewing Staff Member #3, the CNO (Chief Nursing Officer) on 9/29/16 at 3:50 PM, he/she stated the following "I started here the end of April, I am aware of the seclusion and restraint issues, it was the first thing I noticed when I came here. We have conducted Part 1 application of restraint training, and have planned Part 2 regarding paperwork, regulations, order renewals, etc.; we are retraining the supervisors and managers for face to face assessments. We have CPI (Crisis Prevention Institute) trainers, five have been through a new training, all will be recertified. Once done, we will retrain all staff. We also have a BERT (behavioral response team) team to respond to incidents. It as gotten better since I've been here, we have had fewer restraints, that data has improved".
CPI is an international training organization committed to best practices and safe behavior management methods that focus on prevention. One area CPI specializes is "nonviolent crisis intervention", teaching "practical skills and strategies to safely manage disruptive or difficult behavior while balancing the responsibilities of care". (https://www.crisisprevention.com/Specialties; accessed on 10/6/16 at 12:10 PM)

6. A review of the medical record for Patient #7, who was discharged from the facility on 8/11/16, revealed a telephone order written on 8/1/16 at 0835 (8:35 AM) which had not been authenticated by the physician on 9/29/16 when the surveyor reviewed the medical record.

7. A review of Patient #7's medical record revealed the following telephone orders documented on 8/2/16 which had not been authenticated by the physician on 9/29/16 when the surveyor reviewed the medical record:
A. 2 (two) telephone orders documented on the physician order sheet for 8:30 (does not specify AM or PM) (1) for physical hold and (2) for locked seclusion.
B. 1 (one) telephone order documented on the physician order sheet for 1930 (7:30 PM) for a physical hold.
Patient #7 was discharged from the facility on 8/11/16.

8. A review of Patient #7's medical record by the surveyor revealed telephone orders received by the nurse on 8/9/16 at 1030 (does not specify AM or PM) for a physical hold and seclusion. The physician order page had been stamped with the following: "Authenticated by (physician's name) on 8/19/2016 at 08:12:22 AM"; Patient #7 was discharged from the facility on 8/11/16.
At 1:30 PM on 9/29/16 Staff Member #1 stated "This was before I started going around looking at all the charts for Joint Commission".
Staff Member #1 further responded on 9/29/16 at 1:45 PM stating "The doctor has 30 days to complete chart documentation. A report goes to quality every month under delinquencies. There is a score card with point of care audit review of each doctor's charting that is done quarterly with feedback. Doctors get individual letters.
At 1:50 PM on 9/29/16 Staff Member #4, the Assistant Administrator, added "We have never pulled orders or restraint and seclusion on an island-we're going to have to add that category as we go forward".

Findings were discussed with Staff Members #1 and #4 on multiple dates at times throughout the survey process, and again on 9/29/16 between 4:00 PM and 4:30 PM with Staff Members #1, 4, and other members of administration.

The findings were again discussed at the exit meeting on 9/29/16 at 4:00 p.m. with Staff Members #1, 2, 3, 4, 7, 8, and 9.


Zyprexa - an antipsychotic medication used to treat agitation (tense, overanxious, hostile) that occurs with schizophrenia and bipolar mania. It is also used in combination with other drugs to treat depression. The medication can help decrease hallucinations and help the patient think more clearly and feel less agitated. (www.drugs.com accessed 10/6/16 at 4:50 p.m.)

Benadryl - (Diphenhydramine) is an antihistamine used in psychiatric medicine to treat phenothiazine drug-induced abnormal muscle movement (side effects). It is also used in general medicine to treat allergies, allergic reactions, motion sickness, insomnia, cough, and nausea. (www.drugs.com accessed 10/6/16 at 4:50 p.m.)

Based on clinical record review, facility document review and staff interview, the facility staff failed to ensure 2 (two) patients (Patient #3 and #6) who were placed in restraints did not remain in the restraints longer than the required time, based upon age, without a new order.

The findings included:

1. Review of the clinical record for Patient #3 revealed on 9/11/15 the patient was "actively self-injuring by banging head against wall and cutting self on leg. Patient stated, "I cannot help myself" and refused to stop the self injurious behavior...." The record evidences Patient #3 was placed in "mechanical restraint" at 20:45 (8:45 p.m.) and the "end time" was documented as 2330 (11:30 p.m.)- 2 (two) hours and 45 minutes. Patient #3 was between the age of 9 and 17 years of age.

The physician's order dated 9/11/15 at 2100 (9:00 p.m.) read as follows: "Place pt (patient) in mechanical restraint up to 2 (two) hours STAT (immediately) for being a danger to self. To be reevaluated every 2 (two) hours, up to 24 hours per hospital policy. Discontinue restrictive intervention when pt is no longer a danger to self and others."

Review of the facility policy and procedure for "Patient Restraint and Seclusion" evidenced: "...B. Order for Restraint with Violent or Self Destructive Behavior: a. Physicians orders for restraint or seclusion must be time limited and must specify clinical justification for the restraint or seclusion, the date and time ordered, duration of restraint or seclusion use, the type of restraint, and behavior-based criteria for release. Orders for restraint must not exceed:...2. 2 hours for children and adolescents aged 9 to 17 years...b. To continue restraint or seclusion beyond the initial order duration, the RN (registered nurse) determines that the patient is not ready to release and calls the ordering physician to obtain a renewal order..."

On 9/28/16 at 2:20 p.m., the surveyor discussed the finding with Staff Member #1 and 4. Staff Member #1 stated, I cannot find a second order for the restraint, and there is no restraint check sheet for the observation checks."

The findings were again discussed at the exit meeting on 9/29/16 at 4:00 p.m. with Staff Members #1, 2, 3, 4, 7, 8, and 9.


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2. There was documentation in the narrative nursing note of 3 (three) episodes of seclusion for Patient #6 on 2/7/16. The first seclusion was documented as beginning at 0127 (1:27 AM) and ending at 0210 (2:10 AM); the second seclusion was documented beginning at 0213 (2:13 AM) and ending at 0230 (2:30 AM); the third seclusion episode was documented as beginning at 0235 (2:35 AM) and ending at 0320 (3:20 AM).
Documentation on the 2/7/16 Seclusion/Restraints Observation Check Sheet conflicted with the nursing note, evidencing that Patient #6 was in seclusion continuously from 2:55 AM until 5:15 AM, when it was documented that seclusion ended.

3. Documentation in the 2/25/16 nurse's note was that Patient #6 was placed in seclusion twice on that date. The first episode of seclusion was initiated at 15:45 (3:45 PM) and ended on 2/25/16 at 1815 (6:15 PM); the second episode began at 2000 (8:00 PM), and ended at 2245 (10:45 PM).

Findings were discussed with Staff Members #1 and #4 on multiple dates at times throughout the survey process.

The findings were again discussed at the exit meeting on 9/29/16 at 4:00 p.m. with Staff Members #1, 2, 3, 4, 7, 8, and 9.

Based on clinical record review, staff interview and review of facility documents, the facility staff failed to ensure the data collected which identified opportunities for improvement and changes was used to take action to implement changes and ensure that improvements were sustained and that the data monitored the effectiveness of the safety of services and quality of care.

The findings included:

During the review of the Quality Program, the surveyor discussed with facility Staff Member #4 (Assistant Administrator/Quality) and Staff Member #1 the tracking, data collection and monitoring of restraint/seclusion use for the facility.

During the survey areas of concern were identified by the survey team related to the use of restraint and seclusion which included: Obtaining physician orders, orders that were consistent with procedures, authentication of orders, and time limits for orders.

At 1:30 p.m. on 9/29/16, Staff Member #1 stated, in regards to the orders, "This was before I started going around looking at all the charts for Joint Commission...I have only been reviewing the data, I have not been doing an audit of the orders."

Staff Member #1 further responded on 9/29/16 at 1:45 p.m., stating "The doctor has 30 days to complete chart documentation. A report goes to quality every month under delinquencies. There is a score card with point of care audit review of each doctor's charting that is done quarterly with feedback. Doctors get individual letters."

On 9/29/16 at 1:50 p.m., Staff Member #4, the Assistant Administrator, added "We have never pulled orders or restraint and seclusion on an island-we're going to have to add that category as we go forward".

On 9/29/16, at 3:10 p.m., Staff Member #4 stated the staff member who was looking at the restraint orders had left in February, and another person was hired in August but was "looking at the orders retrospectively. During that time there were some changes in leadership and no one was in the office (Quality)...but the team has finally gotten back into their roles..." Staff Member #1 and #4 stated they had "identified issues in February", however, the team identified continued problems with the restraint documentation that continued in August charting.

The survey findings were discussed at the exit meeting on 9/29/16 at 4:00 p.m. with Staff Members #1, 2, 3, 4, 7, 8, and 9.

Based on clinical record review, staff interview and review of facility documents, the facility staff failed to ensure the data collected which identified opportunities for improvement and changes was used to take action to implement changes and ensure that improvements were sustained.

The findings included:

During the review of the Quality Program, the surveyor discussed with facility Staff Member #4 (Assistant Administrator/Quality) and Staff Member #1 the tracking, data collection and monitoring of restraint/seclusion use for the facility.

During the survey areas of concern were identified by the survey team related to the use of restraint and seclusion which included: Obtaining physician orders, orders that were consistent with procedures, authentication of orders, and time limits for orders.

At 1:30 p.m. on 9/29/16, Staff Member #1 stated, in regards to the orders, "This was before I started going around looking at all the charts for Joint Commission...I have only been reviewing the data, I have not been doing an audit of the orders."

Staff Member #1 further responded on 9/29/16 at 1:45 p.m., stating "The doctor has 30 days to complete chart documentation. A report goes to quality every month under delinquencies. There is a score card with point of care audit review of each doctor's charting that is done quarterly with feedback. Doctors get individual letters."

On 9/29/16 at 1:50 p.m., Staff Member #4, the Assistant Administrator, added "We have never pulled orders or restraint and seclusion on an island-we're going to have to add that category as we go forward".

On 9/29/16, at 3:10 p.m., Staff Member #4 stated the staff member who was looking at the restraint orders had left in February, and another person was hired in August but was "looking at the orders retrospectively. During that time there were some changes in leadership and no one was in the office (Quality)...but the team has finally gotten back into their roles..." Staff Member #1 and #4 stated they had "identified issues in February", however, the team identified continued problems with the restraint documentation that continued in August charting.

The survey findings were discussed at the exit meeting on 9/29/16 at 4:00 p.m. with Staff Members #1, 2, 3, 4, 7, 8, and 9.