HospitalInspections.org

Based on document review, video review and interview, it was determined for 1 of 4 (Pt. #1) violent restraints patients and for 2 of 5 (E#1 and E#3) staff involved in restraint application, the Hospital failed to ensure restraint application was performed safely by trained staff, thus putting all potential patients requiring violent restraints at a serious safety threat. Refer to deficiencies at A 144, A 175 and A 194. As a result, it was determined that the Condition of Participation for Patient Rights 482.13 was not in compliance.

1. The Hospital failed to ensure patient safety was maintained during restraint application. See deficiency at A-144.

2. The Hospital failed to ensure patient's were monitored every 2 hours for skin integrity, circulation checks and range of motion as per policy. See deficiency at A 175.

3. The Hospital failed to ensure safe application of the restraints by trained staff. See deficiency at A-194.

Based on document review, video review and interview, it was determined for 1 of 4 (Pt. #1) violent restraint patients, the Hospital failed to ensure patient safety was maintained during restraint application.

Findings include:

1. The Hospital policy titled, "Use of restraints and Seclusion (revised 10/16)" was reviewed on 11/15/16. The policy required, "Restraints and Seclusion will be used in a manner that protects the patient ... will be safely applied

2. The clinical record of Pt. #1 was reviewed on 11/15/16. Pt. #1 was a 34 year old male admitted to the hospital on 11/7/16 with the diagnosis of aggressive behavior. The clinical record included an order dated 11/10/16 at 12:00 PM for physical hold, restraint, seclusion and emergency medication because Pt. #1 physically assaulted a nurse and spit at staff. Pt. #1 was extremely agitated.

3. The video of the restraint occurrence for Pt. #1 was reviewed on 11/15/16 at 11:15 AM. The video start date and time were 11/10/16 at 11:50 AM. The video was reviewed again on 11/16/16 at 8:45 AM. The following was observed:

12:00:01 PM (hour/minute/second) - Three staff entered the room (1 nurse and 2 technicians). The nurse had syringe in hand and Pt. #1 attempted to reach for it. One tech (E#3) threw Pt. #1 on the bed in a prone position and held Pt. #1's head down to the left side with his hand around Pt. #1's neck (fingers at the adams apple and palm on side of throat) for 1 minute and 4 seconds. The other technician grabbed Pt. #1's legs.

12:01:05 PM - E#3 released Pt. #1 from the neck hold and turned patient onto his back.

12:03:27 PM - E#1 placed his left hand around Pt. #1's neck (web of hand at the adams apple) and held a sheet over Pt. #1's nose and mouth with his other hand until 12:04:33 PM (1 minute and 5 seconds). Pt. #1 removed the sheet from his face after E#1 walked away.

4. The CNO (E#4) was interviewed on 11/15/16 at 4:00 PM. E#4 stated, " After seeing the video for the first time this morning, I can see a concern about use of excessive force during restraint application " .

Based on document review, video review and interview, it was determined for 1 of 4 (Pt. #1) violent restraint patients, the Hospital failed to ensure patient's were monitored every 2 hours for skin integrity, circulation checks and range of motion as per policy.

Findings include:

1. The Hospital policy titled, "Use of restraints and Seclusion (revised 10/16)" was reviewed on 11/15/16. The policy required, "The patient will be monitored approximately every 2 hours or sooner according to the patient's condition and need to determine: a. The patient's physical and emotional well being, including ... skin integrity, vital signs and elimination needs. ... e. Whether the restraint has been appropriately applied, via circulation checks and release, passive range of motion and reapplication approximately every 2 hours".

2. The clinical record of Pt. #1 was reviewed on 11/15/16. Pt. #1 was a 34 year old male admitted to the hospital on 11/7/16 with the diagnosis of aggressive behavior. The clinical record included an order dated 11/10/16 at 12:00 PM for physical hold, restraint, seclusion and emergency medication because Pt. #1 physically assaulted a nurse and spit at staff. Pt. #1 was extremely agitated.

3. The video of the restraint occurrence for Pt. #1 was reviewed on 11/15/16 at 11:15 AM. The video start date and time were 11/10/16 at 11:50 AM. The video was reviewed again on 11/16/16 at 8:45 AM.
Many different staff entered the room during restraint episode from 12:04 PM to 4:35 PM to speak to Pt. #1; however, no one was observed checking skin integrity or releasing restraints for range of motion.

4. The video was completed at 12:06 PM. When asked if Pt. #1 was released or monitored per policy, both the Chief Nursing Officer (CNO) (E#4) and Chief of Security (E#5) stated Pt. #1 was not.

Based on document review, observation and interview, it was determined for 2 of 5 (E#1 and E#3) staff involved in restraint application, the Hospital failed to ensure safe application of the restraints by trained staff.

Finding include:

1. The CPI (crisis prevention institute) "nonviolent crisis intervention (reprinted 2016) " training manual was reviewed on 11/16/16. The manual required, "Some restraints are more dangerous than others. For example: face down (prone) and positions in which a person is bent over in such a way that it is difficult to breathe...".

2. The video of the restraint occurrence for Pt. #1 was reviewed on 11/15/16 at 11:15 AM. The video start date and time were 11/10/16 at 11:50 AM. The video was reviewed again on 11/16/16 at 8:45 AM. The following was observed:

12:00:01 PM (hour/minute/second) - Three staff entered the room (1 nurse and 2 technicians). The nurse had syringe in hand and Pt. #1 attempted to reach for it. One tech (E#3) threw Pt. #1 on the bed in a prone position and held Pt. #1's head down to the left side with his hand around Pt. #1's neck (fingers at the adams apple and palm on side of throat) for 1 minute and 4 seconds. The other technician grabbed Pt. #1's legs.

12:01:05 PM - E#3 released Pt. #1 from the neck hold and turned patient onto his back.

12:03:27 PM - E#1 placed his left hand around Pt. #1's neck (web of hand at the adams apple) and held a sheet over Pt. #1's nose and mouth with his other hand until 12:04:33 PM (1 minute and 5 seconds). Pt. #1 removed the sheet from his face after E#1 walked away.

3. The Director of the Behavioral Health Unit (E#1) was interviewed on 11/15/16 at 2:45 PM. E#1 stated that all staff is certified in CPI training annually and provided a refresher every 6 months.

4. The CNO (E#4) was interviewed on 11/15/16 at 4:00 PM. E#4 stated, "After seeing the video for the first time this morning, I can see a concern about use of excessive force during restraint application " . E#4 stated, " There is no policy about using a towel when a patient is spitting, but that is how the staff is trained. The towel is only supposed to cover the mouth, not the nose or face " .