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Based on review of policy, review of restraint log, review of medical records, and interview with staff, the facility failed to ensure a physician's order for restraints in 1 of 1 non violent restrained patients reviewed. (Patient #2)

The findings include:

Review of the facility's policy titled "Restraint of Patients" with revision date of 12/2016, revealed "PURPOSE: The purpose of this policy is to provide guidance for preventing or managing restraint and seclusion so that patient health, safety, dignity, rights and well-being are optimized....DEFINITIONS: Restraint is the direct application of physical force to a patient, with or without the patient's permission, to restrict his or her freedom of movement. The physical force may be human, mechanical devices, or a combination thereof....Physical Hold (manual restraint)--the use of body contact by staff with a patient that restricts freedom of movement or normal access to his or her body is considered restraint."

Closed medical review of discharge summary dated 10/03/2019 at 0840, revealed... Patient #2 revealed the patient, a 60 year old male admitted on 09/15/2019 for increasing aggression and threatening behavior. Review of Nursing note written by RN #1 dated 09/25/2019 at 1454 revealed "The pt (patient) remains in line of sight observation housekeeping staff and sitter staff reported to writer that at when (sic) sitter was redirecting the pt from a peers room the pt became agitated, clinched his fist and attempted to strike sitter but did not make contact, pt was placed in a manual hold and code strong (manner to obtain additional staff response for a patient requiring deescalation) was called...." Review of Security Incident Report (no completion date) revealed "...On are (sic) about 25-09-2019 1030 Security #1 was working on the (patient care floor) as a sitter with Patient #2. Patient #2 began pacing the floor and trying to open doors and to (sic) into another patients rooms as he often does. After pacing for a few hours Patient #2 pushed pass Security #1 and went into another room which was about to be cleaned, Security #1 went into the room and tried to redirect Patient #2 out of the room because it needed to be cleaned by EVS (environmental service) staff. When Security #1 pointed to the door trying to redirecting (sic) Patient #2 that's when Patient #2 swung at Security #1 and do to (sic) Security protecting himself they landed on the floor there were no injuries..." Review of MD #1 progress note dated 09/25/2019 revealed "...Patient assaulted person doing constant observation, unprovoked. Code Strong was called and patient required IM (intramuscular) medication while was held for 5-10 minutes...."

Interview on 02/27/2020 at 1215 with MD #1 revealed Patient #2 received a manual hold when the patient became aggressive with staff. Interview revealed Patient #2 was held for "5-10 minutes" in a manual hold. Interview revealed RN should call for restraint orders.

Interview on 02/27/2020 at 1550 with AS #1 (Director of Quality) revealed nurses should call physicians for restraint orders. Interview revealed policy was not followed.

Interview on 02/27/2020 at 1230 with AS #2 (Director of Patient Care Floor) revealed it is reasonable expectation to notify physician once crisis has been deescalated. Interview revealed the nurses note should contain evidence of notification of the physician. Interview revealed policy was not followed to obtain physician order for restraint.

Based on policy review, medical record review and staff interview, facility staff failed to ensure a time limited order was written for the use of violent restraints for 3 of 3 sampled violent restraint records reviewed (#6, #10 and #5).

The findings include:

Review of the facility's policy titled "Restraint of Patients" with revision date of 12/2016, revealed "PURPOSE: The purpose of this policy is to provide guidance for preventing or managing restraint and seclusion so that patient health, safety dignity, rights and well-being are optimized. ... DEFINITIONS: Restraint is the direct application of physical force to a patient, with or without the patient's permission, to restrict his or her freedom of movement. The physical force may be human, mechanical devices, or a combination thereof. ... Restraints for Violent or Self-Destructive Behavior: refers to the use of restraints in those patients who require management of violent or self-destructive behavior towards themselves or others ... PROCEDURE FOR ORDERING/IMPLEMENTING RESTRAINT: ... Violent/self-destructive behavior (V/SD) requirements ... V/SD restraints time limits for each episode must be specified in the order within these parameters: 4 hours for adults ..."

1. Closed medical record review of Patient #6 revealed a 64 year-old male that was brought to the hospital's emergency department (ED) on 08/27/2019 with a chief complaint of altered mental status. Review revealed the patient was placed under a petition for involuntarly commitment (IVC - determined to be a danger to self or others)). Review of the triage notes recorded the patient had a history of polysubstance abuse and was "belligerent, confused and required restraints for safety." Review revealed the patient was placed in bilateral wrist and ankle restraints on 08/27/2019 at 1715. Review revealed the patient was documented as having confused, agitated, combative and restless behavior. Review revealed the patient was administered Ativan (medication for behavior) 2 mg (milligrams) intravenously (IV) at 1742. Review revealed the restraints were removed at 2145 (4 hours and 30 minutes after applying the restraints). Review of a physician's order dated 08/27/2019 at 1721 revealed an order for "Restraint (Non-Violent) Orders." Review of the restraint order revealed no four hour time limited order placed for the restraint.

Interview on 02/26/2020 at 1530 with RN #6 revealed she was a nurse educator and restraint trainer. Interview revealed restraint orders for Violent restraints required a time limited order of 4 hours for adults. Interview revealed restraints are considered violent restraints when they are used on patients that are a danger to themselves or others. Interview revealed restraints used on a patient who was demonstrating combative behavior would be a violent restraint. RN #6 reviewed Patient #6's restraint record and revealed the patient was placed in restraints for combative behavior and should have a time limited order for a violent restraint written. Interview revealed the restraint order was not consistent with the facility policy.

2. Closed medical record review of Patient #10 revealed a 31 year-old female that was brought to the hospital's ED on 08/18/2019 with a chief complaint of "found wandering the street with increased agitation, loud and combative, no cooperative, history of schizoaffective disorder and substance abuse. Here for evaluation." Review revealed the patient was placed under a petition for IVC. Review revealed the patient arrived via law enforcement in handcuffs. Review revealed the handcuffs were removed at 2015 and Haldol (medication for behavior) 5 mg IM (intramuscular) was administered at 2025. Review revealed bilateral wrists and ankle restraints were placed on the patient at 2100 for combative behavior. Review of a physician's order dated 08/18/2019 at 2221 revealed an order for "Restraint (Non-Violent) Orders." Review of the restraint order revealed no four hour time limited order placed for the restraint.

Interview on 02/26/2020 at 1530 with RN #6 revealed she was a nurse educator and restraint trainer. Interview revealed restraint orders for Violent restraints required a time limited order of 4 hours for adults. Interview revealed restraints are considered violent restraints when they are used on patients that are a danger to themselves or others. Interview revealed restraints used on a patient who was demonstrating combative behavior would be a violent restraint. RN #6 reviewed Patient #10's restraint record and revealed the patient was placed in restraints for combative behavior and should have a time limited order for a violent restraint written. Interview revealed the restraint order was not consistent with the facility policy.

3. Closed medical record review of Patient #5 revealed a 31 year-old male that was brought to the hospital's ED via emergency medical services (EMS) on 08/05/2019 with a chief complaint of "auditory hallucinations." Review of the record recorded the patient was "difficult to redirect, refusing oral medications." Review revealed a plan to administer Haldol and Benadryl (medications for behavior) injectable. Review of the notes recorded the patient "grabbed the fire extinguisher and sprayed staff. Patient placed in restraints via multiple staff." Review revealed police assistance was provided and medications were administered. Review revealed the patient was placed under a petition for IVC. Review revealed bilateral wrists and ankle restraints were placed on the patient on 08/06/2019 at 0001 for combative and agitated behavior. Review of a physician's order dated 08/06/2019 at 0128 revealed an order for "Restraint (Violent) Orders." Review of the restraint order revealed no four hour time limited order placed for the restraint.

Interview on 02/26/2020 at 1530 with RN #6 revealed she was a nurse educator and restraint trainer. Interview revealed restraint orders for Violent restraints required a time limited order of 4 hours for adults. Interview revealed restraints are considered violent restraints when they are used on patients that are a danger to themselves or others. Interview revealed restraints used on a patient who was demonstrating combative behavior would be a violent restraint. RN #6 reviewed Patient #5's restraint record and revealed the patient was placed in restraints for combative behavior and should have a time limited order for a violent restraint written. Interview revealed the restraint order was not consistent with the facility policy.

Based on review of the facility's policy, Quality Improvement Plan, grievance logs, quality indicator data and staff interviews, the hospital staff failed to report quarterly data on the number of grievances received and the actions taken towards resolution.

The findings include:

Review of the policy titled "Complaint and Grievance Resolution for Patients" revised June 2018 revealed "...Reporting: Data collected regarding patient grievances ...will be trended by Risk Management and reported to the Patient Safety Clinical Quality Committee by the Quality Department for incorporation into the hospital's overall performance improvement program. On a quarterly basis and annually, the Risk Manager or designee will prepare a report for the Board consisting of the status of all grievances received (numbers, types, and trends) and actions taken ..."

Review of the "2019 Performance Improvement Plan-Patient Safety & Clinical Quality" policy approved March 2019 revealed the hospital " ...has developed and implemented an integrated Patient Safety and Clinical Quality Performance Improvement Plan (PSCQ Plan) to provide a foundation for continuous assessment, evaluation, and improvement of patient care services, improved patient safety outcomes and organizational performance...Reporting...All patient safety/clinical quality performance improvement results will be reported...The report should include: Performance goal; Current results as well as previous results to allow for trending of the results; Brief analysis, noting trends or recent process changes that may have impacted results; Description of actions taken and actions to be taken..."

Review of the hospital's "Process Improvement Project Reporting" schedule for 2019 revealed the Quality/Patient Safety/Risk departments were scheduled to report on "Complaints/Grievances" once in February 2019. Review failed to reveal evidence there was quarterly reporting on "Complaints/Grievances" per the hospital's policy.

Review of the February 2019 "Grievance" data presented by the Quality Department revealed the number of grievances received and the type of grievances were tracked and reported to the PSCQC. Review failed to reveal evidence that the status of the grievances and actions taken were reported to the Board, per hospital policy.

Interview on 02/27/2020 at 1100 with the Director of Quality (AS #1) revealed the hospital tracked the number of grievances received by each hospital unit and the nature of the grievance. Interview revealed the data was reported to the PSCQC annually in February. Interview revealed there was no quarterly reporting on grievances to the PSCQC or to the Board. Interview revealed the actions taken by the Quality Department and the time for grievance resolution was not reported to the PSCQC or to the Board. Interview revealed the members of the Board "trust that the staff has resolved the grievances timely."

Based on review of policies, review of incident report log, review of medical records, and interviews with staff, the facility staff failed to ensure tracking of patient safety events by failing to complete an incident report for 1 of 1 records that documented a security event and failing to contact a physician about a change in condition (#2).

The findings include:

Review of the facility's policy titled "Confidential Incident Report" with revision date of 07/2019, revealed "PURPOSE: To set forth procedures for the non punitive reporting, documentation and investigation of incidents or near misses involving patients...To identify those incidents that will be reported to the (Name of the Patient Safety Organization). DEFINITIONS: Incident: Any actions, circumstances or events which might reasonably be expected to result in a claim or legal action against the organization for damages. These actions, circumstances or events may or may not involve physical injury to property or bodily injury to person. PROCEDURE: Any staff member who identifies an incident is responsible for reporting the incident and for completing the Confidential Incident Report in RL Solutions....2. The confidential incident report form from the RL Solutions should be completed within 24 hours of the incident. 3. The Confidential Incident Report will automatically forward to the administrator to the Quality Management Department....Confidential Incident Report---This list is for examples only and meant to be a guide and not meant to be all inclusive....Service Delivery: ...Use of seclusion or restraint, No MD order..."

Review of an incident report log dated September 2019 through January 2020 revealed no documentation of an incident report for Patient #2.

1. Closed medical (record) review of the "Discharge Summary"dated 10/03/2019 at 0840 for Patient #2 revealed the patient, a 60 year old male admitted on 09/15/2019 for increasing aggression and threatening behavior. Review of the "Nurses Progress Note" written by RN #1 on 09/25/2019 at 1454, revealed "The pt (patient) remains in line of sight observation housekeeping staff and sitter staff reported to writer that at when sitter was redirecting the pt from a peers room the pt became agitated, clinched his fist and attempted to strike sitter but did not make contact, pt was placed in a manual hold and code strong (manner to obtain a response for patient requiring deescalation) was called...." Review of the"Security Incident Report" (no completion date) revealed "...On are (sic) about 25-09-2019 1030, Security #1 was working on the (patient care floor) as a sitter with Patient #2. Patient #2 began pacing the floor and trying to open doors and to into another patients rooms as he often does. After pacing for a few hours Patient #2 pushed pass Security #1 and went into another room which was about to be cleaned, Security #1 went into the room and tried to redirect Patient #2 out of the room because it needed to be cleaned by EVS staff. When Security #1 pointed to the door trying to redirecting (sic) Patient #2 that's when Patient #2 swung at Security #1 and do to (sic) Security protecting himself they landed on the floor there were no injuries..." Review of MD #1 progress note dated 09/25/2019 revealed "...Patient assaulted person doing constant observation, unprovoked. Code Strong was called and patient required IM (intramuscular) medication while was held for 5-10 minutes...."

Interview was requested on 02/25/2020 for RN #1. RN #1 is no longer employed at the facility and was not available for interview.

Interview on 02/26/2020 at 1410 with Security #1 revealed Patient #2 required a sitter that shift. Interview revealed Patient #2 became aggressive and attempted to "hit me" and "we both went to the floor." Interview revealed a Code Strong was called and the "nurse gave him some medications." Interview revealed no incident report was completed regarding the incident.

Interview on 02/27/2020 at 1550 with AS #1 (Director of Quality) revealed an incident report should have been completed due to the "need to track incidents." Interview revealed hospital policy was not followed.

2. Closed medical record review of the discharge summary dated 10/03/2019 at 0840, revealed Patient #2 was a 60 year-old- male admitted on 09/15/2019 for increasing aggression and threatening behavior. Review of the "Nurses Progress Note" of RN #2 dated 09/23/2019 at 2302, revealed "Group note: 2025 emesis x (times) 1, PRN (as needed) Zofran 2054, emesis 2200 x 1, emesis 2234 x 1 clear with med capsule. Phoned on-call Medical. Mailbox full unable to leave message." Review of the "Nurses Progress Note" dated 09/24/2019, RN #2 wrote "In room most of shift. Emesis x 5. Did fall asleep and was quiet. PRN (as needed medication) given with meds, took all meds. Phoned medical (sic) on call, voicemail full. Phoned ER (emergency room), did not return call. Pt resting quietly, no further emesis noted...."

Interview requested on 02/26/2020 with RN #2. RN #2 is no longer employed at facility and was not available for interview.

Interview on 02/27/2020 at 1550 with AS #1 (Director of Quality) revealed an incident report should have been completed due to the "need to track incidents." Interview revealed the hospital policy was not followed.

NC00156503; NC00156397; NC00155787