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Based on policy review, medical record review, and staff interviews facility staff failed to ensure chemical restraints were not ordered PRN (as needed) for 1 of 2 sampled chemical restraints (Patient #11).

The findings include:

Review of facility policy titled "Restraints/Protective Devices" revised 03/2021 revealed "...1. Prevent, reduce and eliminate the use of restraints by: ...2. Limiting use of restraints only to emergencies where there is risk of the patient harming himself/herself or others, using the least restrictive method possible..." Review revealed the facility policy failed to include PRN restraint use.

Review on 12/09/2021 of a closed medical record for Patient #11 revealed a 15-year-old male who presented to the emergency department (ED) on 11/25/2021. Review of the ED Physician Note dated 11/25/2021 at 0356 revealed "... Plan IVC (involuntary commitment) completed prior to arrival. Due to reported attempts to harm family, rather directly or indirectly, will transfer to behavioral health unit for eval (evaluation) by psych...." Review of the "Emergency Department (named unit) Holding Order Set dated 11/25/2021 at 0345 revealed "... INDICATION: ACUTE PSYCHOSIS WITH AGGRESSION AND AGITATION BENADRYL (medication for behaviors) 25 MG (milligrams), HALDOL (antipsychotic medication) 5 MG AND ATIVAN (medication for anxiety) 2 MG IM (intramuscular injection) (ONE TIME ONLY) [PRN]..." Review revealed Patient #11 did not receive the one time order for Benadryl, Haldol, and Ativan. Review of Patient #11's MAR (medication administration record) revealed Benadryl 25mg, Ativan 2mg, and Haldol 5mg were available for administration by nursing with a one time PRN order for acute psychosis with aggression and agitation. Review revealed Patient #11 remained in the Emergency Department pending psychiatric placement/transfer.

Interview on 12/09/2021 at 1123 with the Chief Nursing Officer Revealed that the Holding order set for Haldol, Ativan, and Benadryl was a chemical restraint. Interview confirmed restraints should not be ordered PRN. Interview confirmed a PRN restraint order does not follow facility policy of limiting restraints to emergencies where there is risk of the patient harming themselves or others.

Interview requested on 12/09/2021 at 1136 revealed the ED Medical Doctor who cared for Patient #11 was unavailable.

Interview on 12/09/2021 at 1145 with the ED Medical Director revealed that Ativan, Benadryl, and Haldol are used when a chemical restraint is needed. Interview revealed that the ED Holding Order set has a one-time PRN order set for Ativan, Haldol, and Benadryl to be given for acute psychosis with aggression, and agitation. Interview revealed nursing staff "usually call us (providers) and let us know" that the patient is acting aggressive. Interview confirmed chemical restraints should not be ordered PRN. Interview revealed that the nursing staff had the order so that if they (nurses) decided the patient needed it that the medications could be pulled immediately instead of waiting to notify a provider and wait for new orders. Interview revealed all patients that are transferred to the Behavioral Health holding unit in the emergency department receive the orderset for the one time PRN dose of Ativan, Haldol, and Benadryl IM. Interview confirmed Patient #11 had not needed the PRN medications for Benadryl, Haldol and Ativan however it was there in case he did.

Based on facility policy review, facility restraint education review, provider restraint education review, medical record review, and staff interview, facility nursing staff failed to supervise restrictive interventions to ensure the least restrictive measures were implemented prior to initiating restraints on 2 of 3 violent restraint records reviewed (Patient #4, and Patient #11); and failed to ensure an order was obtained for a restraint on 1 of 3 violent restraint records reviewed (Patient #4).

The findings include:

Review of facility policy titled "Restraints/Protective Devices" revised 03/2021 revealed "...All patients have the right to be free from restraints or seclusion, of any form, that is not medically necessary or are used as means of coercion, discipline, convenience, or retaliation by staff.. By respecting these tenets of human dignity, and self-determination, restraints shall be employed only when alternative/least restrictive measures are not successful in assuring safe medical care of the patient... Exemptions to Restraint Usage ... 4. Therapeutic holding is not a restraint ... 8. Forensic and law enforcement correction restrictions used for security purposes, ie (example)., handcuffs. Handcuffs ... shackles or other law enforcement items are not appropriate health care measures and cannot be utilized to restrain patients ..."

Review of the online education module for restraints on 12/10/2021 revealed education was provided to all clinical staff upon hire, and annually. Review revealed de-escalation techniques, and "...Guidelines for Restraint Usage... Restraint and Seclusion are only used when clinically justified..."

Review of the provider education for restraints on 12/10/2021 revealed education was provided to all providers upon hire and annually. Review revealed "...TYPES OF RESTRAINTS... Violent/Self-destructive restraints are implemented to protect the individual against injury to self or others resulting from an emotional or behavioral disorder. These standards apply to any patient regardless of the setting who presents with extreme agitation and/or dangerous behavior...RESTRAINT ASSESSMENT AND DOCUMENTATION The events that led up to the initiation of restraints must be evident in the record. In addition, all alternatives and interventions to keep the patient out of restraints must be documented in the record as well..."

1) Review of an open medical record on 12/10/2021 revealed Patient #11 was a 15-year-old male who presented to the ED on 11/25/2021 under IVC (Involuntary Commitment). Review of the ED Provider Note dated 11/25/2021 at 0356 revealed " ...15 yo (year old) M (male) with conduct disorder and BPD (bipolar disorder) ... after attempting to set his mother's house on fire with a makeshift torch ..." Review of Nursing documentation revealed Patient #11 eloped from the facility on 11/26/2021 at 1430. Review revealed the Sheriff's department as well as the Patient's mother were notified. Review revealed Patient #11 was returned to the facility at 1514 by the Sheriff's Department. Review of the Violent/Self Destructive Behavior Restraint orders revealed "...Initiation of Restraints Date 11/26/2021 Time 1520 Duration: __ hours... Indications for Restraint Use: Prevent imminent danger to self and/or others... Type of Restraint: Extremities... LUE (left upper extremity) RUE (right upper extremity) LLE (left lower extremity) RLE (right lower extremity) ... Review revealed the order was not signed by the provider. Review of the Violent/Self Destructive Behavior Restraint orders revealed "... Continuation of Restraints Date 11/26/2021 Time 1730 Duration 2 hours Type of Restraint:... RUE..." signed by the provider on 11/26/2021 at 1730. Review of the One Hour Face to Face Assessment: Patient in Violent Restraints dated 11/26/2021 at 1730 revealed "...Reason for Restraint/Seclusion... Other: Danger of harming staff in order to Elope... Behavioral Assessment He plays nice and cooperative, but he's very manipulative and we can't trust that he won't try to force himself past staff to leave..." Review revealed on 11/26/2021 at 1600 the Left lower extremity was released from restraint, at 1630 the Right lower extremity was released, at 1645 the left upper extremity was released, and at 1932 the right upper extremity was removed. Review of nursing documentation revealed during the times of 1520 through 1932 Patient #11 was cooperative, and followed safety directions. Review revealed Patient #11 was still a patient in the ED.

Interview on 12/09/2021 at 1000 with RN #5, the charge nurse working on 11/26/2021 revealed she recalled the incident with Patient #11 eloping. Interview revealed she was unaware of what occurred prior to Patient #11's elopement. Interview revealed after Patient #11 was returned by the sheriff's she was instructed by NP #6 to place Patient #11 in 4-point restraints and handed the written order. Interview revealed she was informed "he needed to go in restraints because he had eloped". Interview revealed if she is told to put a patient in restraints with an order that she will not question the order. Interview revealed at the time of restraint application Patient #11 was visibly upset and crying, but was calm and cooperative.

Interview on 12/09/2021 at 1055 with NP #6 revealed she recalled Patient #11. Interview revealed when Patient #11 was brought back by the sheriff's department, "Initially they just put him back in the bed, and he was sitting up and looking around. I thought that he could easily overpower the staff so I said let's put him in restraints until we know how he is going to act." Interview revealed there were no other less restrictive interventions attempted. Interview revealed Patient #11 was put in 4-point restraints to prevent him from eloping again.

Interview on 12/09/2021 at 1123 with the Chief Nursing Officer confirmed that ordering restraints to prevent a patient from eloping does not follow facility policy. Interview revealed the facility leadership was unaware that the provider ordered a restraint to prevent a patient from eloping.

2) A closed medical record review on 12/08/2021 for Patient #4 revealed an 18-year-old female who presented to the Emergency Department (ED) on 06/18/2021 with suicidal ideation and attempts. Review of the ED note dated 06/18/2021 at 0347 revealed "... Patient here for SI (suicidal ideation) on IVC (involuntary commitment) by police.... She requires psychiatric evaluation and admission. She is medically cleared..." Review of the Patient Progress Notes dated 06/18/2021 at 0845 by RN #1 revealed "PT BECOMES UPSET AFTER SHE TORE UP A CUP AND TRIED TO PUT IT IN HER MOUTH. SHE BECAME VIOLENT AND WAS TRYING TO BANG HER HEAD ON THE WALL. SHE WAS GIVEN B52 (Benadryl 25mg, Haldol 5mg, and Ativan 2 mg Intramuscular) INJECTIONS. PATIENT IS KICKING AND ATTEMPTING TO BITE STAFF. SHE BIT SECURITY OFFICERS ARM. SHERRIFS DEPARTMENT NOTIFIED..." Review of Patient progress notes dated 06/18/2021 at 0900 by Patient Safety Attendant #2 revealed "Approx (approximately) 830 pt (patient) was pick (sic) at her stomach wound nurse asked for me to help so she could see this wound. paient (sic) went to sink and grab a small plastic cup and tore it in half. I grab the cup from pt and pt went to hit her head. i (sic) grab patient and cradled her head so she could not hurt herself. security came to assist with holding patient while nurse went to get meds (medications). Law was called and when arrived they assisted with getting patient to room. and was restrained to floor in room 6..." Review of Violent/Self Destructive Behavior Restraint Orders revealed "...Initiation of Restraints Date 06/18/2021 Time 0900 Indications for Restraint Use Prevent imminent danger to self and/or others To administer stat (immediate) IM (intramuscular) psychotropic medication due to active dangerous behavior to self and/or others. Type of Restraint: Extremities ... Handcuffs per LE (law enforcement) Chemical Restraint Haldol 5 mg (milligrams) Ativan 2 mg Benadryl 25mg IM x (times) 1 dose STAT...)." Review of the Patient Progress Notes dated 06/18/2021 at 1145 revealed "... Readiness for D/C (discontinue) of Restraint" Yes - restraints d/c'd (discontinued), Patient is now arousable with verbal stimuli. She is able to ask officer to remove handcuffs..." Review revealed on 06/18/2021 at 1930 the Police officer removed Patient #4's handcuffs and left the ED. Review of the Patient Progress Notes dated 06/19/2021 at 2112 revealed "Pt then got up & (and) left the unit. at this time red button was pushed and leo (law enforcement officer) called. in the hallway pt was restrained after kicking PA (named) 2 x's (times). pt also attempted to bite (named staff). pt was given prn (as needed) injection then came back to the unit on her own. leo showed & pt continued to calm down. Review of the Patient Progress Notes at 2130 revealed "Restraints Initiated... Situation leading up to Need for Restraint: Pt was angry, attempting to hit/kick staff, attempting to bite staff... Alt (alternative) Measures Attempted and Failed: Increased monitoring, Education r/t (related to) treatment/procedures, Reorientation. Decreased Stimulation, Diversional Activities... Type of Restraint: Chemical: B52..." Review revealed no order for a chemical restraint or a manual hold for B52, or restraint in the hallway. Review revealed no documentation of the length of restraint that occurred in the hallway, or an end time for the chemical restraint. Review of the Patient Progress Notes dated 06/21/2021 at 1620 revealed "pt extremely upset because she can't go home, rushed pt nurse yelling and cussing up hall and busted out side door-pt ran across parking lot- sheriff's department called - awaiting response." Review of the Patient Progress Notes at 2043 revealed " Pt returned to (named unit) at 2000 per (named County) Deputy... pt physically charging at staff even while handcuffed. deputy interviened (sic) and pt is now in cuffs & shackled to floor as per policy. Deputy at bed side..." Review revealed no documented interventions for aggressive behavior. Review of the Patient Progress Notes dated 06/24/2021 at 1945 revealed "...at approx 1945 pt accompanied by another pt(named) and eloped out of the (named unit). patients waited for security to leave to do rounds before making a run out the doors. LEO notified, security notified, er (emergency room) personnel notified will follow..." Review of the Nurses note at 2145 revealed "... approx 2145 LEO (named county) returned pt..." Review of the Nursing Notes at 2244 revealed "pt arguing with staff, slamming doors. pt kicked mattress and refuses to lay down... pt refuses to stay in room at this time. pt is not violent but states she will be violent and aggressive if she cannot leave tomorrow... LEO states to call them if pt starts getting physical..." Review of the Against Medical Advice Patient Acknowledgment revealed Patient #4 signed an AMA form on 06/25/2021 at 0956. Review revealed Patient #4 was given risks and benefits of leaving by a Medical Doctor. Review of Nursing documentation revealed on 06/25/2021 at 1025 Patient #4 left AMA (against medical advice) after her IVC expired.

Interview requested on 12/08/2021 at 0942 with PSA #2 who cared for Patient #4 on 06/24/2021, revealed he was unavailable for interview.

Interview requested on 12/08/2021 at 0942 with RN #3 who cared for Patient #4 on 06/24/2021, revealed she was unavailable for interview

Interview on 12/08/2021 at 1000 with RN #1 revealed she recalled Patient #4. Interview revealed the Handcuffs should not have been documented on the order for the restraint. Interview revealed she does not document on handcuffs when law enforcement places them on a patient. Interview revealed Patient #4 required a manual hold to administer the chemical restraint. Interview revealed RN #1 was unaware that a manual hold was a restraint that required an order. Interview revealed physical restraints were not an option on the unit where behavioral health patients are held. Interview revealed "it has to be metal to metal to the metal ring on the floor." Interview revealed the unit was a ligature free unit. Interview revealed when patient's become aggressive with staff that they call the sheriff's department to come and assist, and it is up to the sheriff if the patient becomes handcuffed.

Interview on 12/08/2021 at 1441 with the Clinical Resource Specialist revealed that restraint training consists of an online education module upon hire and annually. Interview revealed there is no education on manual holds. Interview revealed that preceptors are responsible for providing hands on education on restraints to new hires. Interview revealed there is no specific requirements to be able to train on restraints.

Interview on 12/08/2021 at 1520 with the Chief Nursing Officer revealed that there were metal rings on the floor in the behavioral health area in order to be able to safely restrain patients. Interview revealed there should be a mattress on the floor and the restraints would quick release tie to the metal rings on the floor. Interview confirmed the least restrictive interventions should be utilized prior to initiating restraints.

Interview on 12/08/2021 at 1525 with the ED Nurse Manager revealed she was unaware that the metal rings on the floor were for restraints. Interview revealed the Nurse Manager was under the impression that that there was no ability to use a physical restraint on a patient in the behavioral health area.

Interview on 12/08/2021 at 1544 with MD #4 who cared for Patient #11 on 06/18/2021 revealed that the handcuffs were documented on the order form to notate what was occurring. Interview revealed the order was for a chemical restraint. Interview revealed he was not ordering the handcuffs to be applied. Interview revealed the law enforcement officer had already applied the handcuffs. Interview revealed there were no less restrictive interventions due to the handcuffs on the patient.

Based on policy review, medical record review, incident log review, and staff interview, facility staff failed to report 2 of 3 behavioral health patient elopements (Patient #4, Patient #12)

Findings include:

Review of facility policy titled "Adverse Event Policy" with a revised date of 02/2018 revealed "... Definitions Adverse Event Any unexpected incident, occurrence, or circumstance that is not consistent with routine patient care or operations of the facility that either did or could directly result in injury or has potential to cause harm or injury... All adverse events should be reported as soon as possible after detection. Who Reports: Any staff member who is involved, observes, or first becomes aware of the Adverse Event..."

1) Review of a closed medical record on 12/08/2021 for Patient #4 revealed an 18-year-old female who presented to the Emergency Department (ED) on 06/18/2021 with suicidal ideation and self-harm attempts. Review of the ED note dated 06/18/2021 at 0347 revealed "... Patient here for SI (suicidal ideation) on IVC (involuntary commitment) by police.... She requires psychiatric evaluation and admission. She is medically cleared..." Review of the Patient Progress Notes dated 06/19/2021 at 2112 revealed "Pt then got up & (and) left the unit. at this time red button was pushed and leo (law enforcement officer) called of the Patient Progress Notes dated 06/21/2021 at 1620 revealed "pt extremely upset because she can't go home, rushed pt nurse yelling and cussing up hall and busted out side door pt ran across parking lot - sheriff's department called - awaiting response. Review of the Patient Progress Notes at 2043 revealed "Pt returned to (named unit) at 2000 per (named County) Deputy..." Review of the Patient Progress Notes dated 06/24/2021 at 1945 revealed "...at approx 1945 pt accompanied by another pt(named) and eloped out of the (named unit). patients waited for security to leave to do rounds before making a run out the doors. LEO notified, security notified, er (emergency room) personnel notified will follow..." Review of the Nurses note on 06/24/2021 at 2145 revealed "... approx 2145 LEO (named county) returned pt..." Review of the Against Medical Advice (AMA) Patient Acknowledgment revealed Patient #4 signed an AMA form on 06/25/2021 at 0956. Review revealed Patient #4 was given risks and benefits of leaving by a Medical Doctor. Review of Nursing documentation revealed on 06/25/2021 at 1025 Patient #4 left AMA (against medical advice) after her IVC orders expired.

Review of the facility incident log on 12/07/2021 revealed no incidents reported for Patient #4 related to elopements on 06/19/2021, or 06/24/2021.

Review of a facility incident report for Patient #4 on 12/07/2021 revealed Patient #4 eloped from the facility on 06/21/2021. Review revealed the Nurse Manager's review and investigation indicated that Patient #4 was returned to the department via Sheriff's officers. Review revealed no further investigation was completed.

Interview requested on 12/08/2021 at 0942 with PSA #2 who cared for Patient #4 on 06/24/2021, revealed he was unavailable for interview.

Interview requested on 12/08/2021 at 0942 with RN #3 who cared for Patient #4 on 06/24/2021, revealed she was is unavailable for interview.

Interview on 12/08/2021 at 0943 with the ED Nurse Manager revealed that the expectation was when an elopement of a patient occurred, the staff notified leadership, and completed an incident report. Interview confirmed facility policy was not followed.

Interview on 12/08/2021 at 0945 with the Chief Nursing Officer revealed she was unaware of Patient #4's elopements from the ED on 06/21/2021 and 06/24/2021. Interview revealed the expectation was for an incident report to be completed for any patient elopement. Interview confirmed facility policy was not followed.

2) Review of a closed medical record on 12/09/2021 for Patient #12 revealed a 16-year-old female who presented to the ED on 06/20/2021 with complaints of SI and depression. Review of the Patient Progress Notes by RN #3 on 06/24/2021 at 1945 revealed "...At approx 1945 pt accompanied by another pt (Patient #4) and eloped out of the (named unit). patients waited for security to leave to do rounds before making a run out the doors. LEO notified, security notified, er personnel notified will follow. house security quickly found pt and called LEO for assist..." Review of the Patient Progress notes at 2145 revealed "...approx 2145 LEO (named county) returned pt to ER... LEO assisted pt over to (named unit)..." Review revealed Patient #12 was discharged on 06/26/2021.

Review of the facility incident log on 12/07/2021 revealed no incidents reported for a Patient #12 related to an incident on 06/24/2021.

Interview requested on 12/08/2021 at 0942 with PSA #2 who cared for Patient #12 on 06/24/2021, revealed he was unavailable for interview.

Interview requested on 12/08/2021 at 0942 with RN #3 who cared for Patient #12 on 06/24/2021, revealed she was unavailable for interview.

Interview on 12/08/2021 at 0943 with the ED Nurse Manager revealed that the expectation was if an elopement of a patient occurred staff would notify leadership and complete an incident report. Interview confirmed facility policy was not followed.

Interview on 12/08/2021 at 0945 with the Chief Nursing Officer revealed she was unaware of the patient elopements from the ED. Interview revealed the expectation was for an incident report to be completed for any patient elopement. Interview confirmed facility policy was not followed.

NC00182369