HospitalInspections.org

Based on document review and interview, it was determined that for 2 of 4 clinical records (Pts. #1 and #3) reviewed for restraint use, the Hospital failed to ensure that the use of restraint was in accordance with the order of a physician/licensed practitioner.

Findings include:

1. The Hospital's policy titled "Restraint and/or Seclusion Use and Indications in the Acute Care Setting" (revised 9/14/2020), was reviewed on 7/7/2021 and required, "...If a patient was released from restraint and exhibits behavior that can only be managed through the reapplication of restraint, a new order is required... If Violent / Self-destructive restraint is necessary, it may be applied only under the order of a physician... If a trained RN [registered nurse] initiates Violent / Self-destructive restraint, a physician's confirming order is obtained within minutes of imposing the restraint... Each violent / self-destructive / behavioral restraint order is time limited and may be renewed... as follows: Adult age 18+ years: 4 hours (maximum)..."

2. The clinical record of Pt. #1 was reviewed on 7/6/2021. Pt. #1 presented to the Emergency Department (ED) on 4/23/2021 at 4:38 PM for a mental health evaluation with diagnoses of alcohol intoxication, suicidal ideation, and COVID-19. Pt. #1's record indicated that 4-point (violent) restraints were ordered on 4/23/2021 at 4:49 PM, for 4 hours, due to Pt. #1 displaying physical/verbal threatening behavior. Pt. #1 remained in 4-point restraints from 4:49 PM until 9:27 PM (4 hours and 38 minutes). The record lacked a new physician's order for restraints after the first restraint order expired at 8:49 PM.

3. The clinical record of Pt. #3 was reviewed on 7/6/2021. Pt. #3 presented to the ED on 7/5/2021 at 2:32 PM with a diagnosis of suidcal ideation. Pt. #3's record indicated that 4-point (violent) restraints were ordered on 7/5/2021 at 2:47 PM, for 4 hours, due to Pt. #3 displaying physical/verbal threatening behavior. Pt. #3 was initially restrained on 7/5/2021 from 2:47 PM to 4:51 PM. A Nurse's Note on 7/5/2021 at 4:52 PM included, "Restraints removed... Pt is calm and cooperative at this time..." Another Nurse's Note on 7/5/2021 at 5:51 PM included, Pt coming out of room, yelling at staff.. Pt placed in 4 point restraints. The record indicated that Pt. #3 was placed in violent restraints again from approximately 6:10 PM to 9:20 PM. The record lacked a new physician's order for the reapplication of restraints.

4. Interviews were conducted with the ED Educator (E#4) on 7/6/2021 at 12:10 PM and again on 7/7/2021 at 1:25 PM. E#4 stated that a new physician's order is required if restraints need to be reapplied, as these are two separate episodes of restraint. E#4 stated that for adults, a new order must be placed if behavioral/violent restraint use is to exceed the 4 hour time limit.

Based on document review and interview, it was determined that for 1 of 4 patients' (Pt. #1) clinical records reviewed for restraint usage, the Hospital failed to ensure the restraint was discontinued at the earliest possible time.

The findings include:

1. On 7/7/2021, the Hospital's policy titled, "Restraint and/or Seclusion Use and Indications in the Acute Care Setting" (last revised 9/14/2020), was reviewed and indicated, " ...9. Restraint use is minimized and removed at the earliest possible time when the patient's behavior assessment determines the need for restraint or seclusion is no longer needed or that the patient's needs can be addressed using less restrictive methods ..." and " ...C. Violent/Self Destructive/Behavioral Restraint ... 9. Patients are released from violent/self-destructive/behavioral restraint when the criteria to discontinue restraint are achieved. Examples of this criteria are: a. patient is no longer violent/aggressive or putting self or others in danger. b. patient is calm and cooperative."

2. On 7/6/2021, Pt#1's clinical record was reviewed and indicated that Pt#1 arrived at the Emergency Department (ED) on 4/23/2021 at 4:38 PM. Pt#1 arrived at the Emergency Department (ED) via Emergency Medical Services, in restraints and had a "Petition for Involuntary Admission". Pt#1's chief complaint was mental health evaluation, and visit diagnosis were; alcohol intoxication, suicidal ideation, and COVID-19.

-Pt#1's record indicated that 4-point violent/behavioral restraints were ordered on 4/23/2021 at 4:49 PM, for 4 hours, due to Pt#1 displaying physical/verbal threatening behavior. Pt#1 was placed in 4-point restraints from 4:49 PM until 9:27 PM.

-On 4/23/2021 at 7:34 PM, a Nurse's Assessment included that Pt#1 continued to need restraints; however, every 15 minute monitoring sheets indicated that from 6:45 PM to 9:30 PM, Pt. #1's behavior was documented as quiet, sleeping, or follows direction.

-The record indicated that restraints were not removed until 9:27 PM (2 hours and 38 minutes after Pt. #1 was initially documented as quiet/sleep). The record lacked clinical justification of continued restraint use.

3. On 7/7/2021, at approximately 11:00 AM, an interview was conducted with the Nurse Educator (E#4). E#4 stated that when restraints are removed, it is done as a group effort. The nurse, physician, and security need to be involved in order to maintain safety. So, once a patient has been determined to be safe, it can take a little bit before the restraints are actually removed, but it shouldn't take hours for the restraints to be removed.