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Based on policy review, medical record review and staff interviews, hospital staff failed to recognize a physical hold for a forced medication or to emergently manage aggressive/ violent behavior as a restraint and failed to obtain orders for the physical holds for 1 of 7 Emergency Department (ED) psychiatric patient records reviewed (Patient #4).

The findings included:

Review of the restraint policy, last revised 12/2019, revealed "...DEFINITIONS: Physical Restraint: A restraint is any manual method, physical or mechanical device....that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely... ." Policy review did not reveal any specific instructions or statements related to physical holds or forced medications.

Medical record review for Patient (Pt) #4, on 01/26-27/2021, revealed the 17 year old arrived to the ED on 11/23/2020 at 2321 with a stated complaint of "SENT FROM GROUP HOME FOR PSYCH EVAL (psychological evaluation)". Review of an ED Physician Note titled "EMERGENCY DEPARTMENT REPORT HPI (History and Physical)...", time seen 2225, revealed "...brought in....from Group home.... has been acting out and disruptive.... reports abrasion to the forearm when she attempted to break a glass bottle on the counter. Denies any suicidal ideation (thoughts to harm/kill self) or homicidal ideation (thoughts to hurt others).... Review revealed a medical history that included Conduct Disorder (mental health disorder that can occur in children and teens with aggressive/destructive behavior and disregard for others), Bipolar Disorder (mental health disorder with mood swings ranging from depressive lows to manic highs), ADHD (Attention deficit hyperactivity disorder, chronic condition with attention difficulty, impulsiveness, hyperactivity) and mild IDD (Intellectual or developmental disability). Review of "Nursing Documentation", dated 11/24/2020 at 1905, revealed "PATIENT SLAMMING DOOR AND RUNNING WATER AND THROWING IT. TRIED TO GET PATIENT IN BED AND STARTED SWINGING. SECURITY IN ROOM AND PATIENT HELD IN BED UNTIL MEDICATIONS OBTAINED....GEODON (antipsychotic medication) 10 MG (milligrams) GIVEN IN LEFT LEG. PATIENT SCREAMING AND CRYING. STAYED WITH PATIENT AND CALMED HER DOWN. ..." Review of "Nursing Documentation, revealed on 11/30/2020 at 0840, "PATIENT BECAME DISRUPTIVE, PULLED PLASTIC STICKER HOLDER OFF OF WALL ALONG WITH SCREWS THAT HAD IT ATTACHED TO WALL. PATIENT UNCOOPERATIVE.....REFUSED TO GET BACK INTO BED AND SAT ON FLOOR....PATIENT WAS ASSISTED OUT OF FLOOR AND INTO BED BY 3 STAFF MEMBERS. GEODON 10 MG WAS GIVEN....PT APOLOGETIC AFTER INJECTION...." On 12/09/2020 at 1550, "Nursing Documentation" revealed "Pt arguing with sitter, pushing bedside table towards her....patient climbed under table and started hitting the sitters legs. Hollaring (sic)....Pt corrected by (name) and myself, 'that behavior is not nice and we cannot allow you to abuse our staff that way.' Pt started banging head on wall....MD made aware of pt's behavior and in room to assess pt. At 1600, a comment revealed "Pt medicated with assistance from security x 3 (3 security staff), ED tech so pt could receive medication safely without doing any harm to herself." On 12/11/2020 at 0745, "Nursing Documentation" stated "...Code Gray was called when patient tried to push past sitter to leave facility. Security responded, pt was medicated per orders and helped to bed. pt was hitting, kicking staff, screaming, refusing to sit on teh (sic) bed, resisting being medicated." On 12/16/2020 at 2221, "Assessment Data" Comments noted "PT PUNCHING WALL AND PUNCHING PLEXI GLASS OVER TV, TAKING STRETCHER AND PULLED MATTRESS OFF AND STARTED GRABBING STRETCHER AND SLAMMING THE BED....2212....PT CONTINUES TO WALK OUT OF ROOM AND TAUNT THE SITTER....PT TRIED TO RUN OUT THE EMS DOORS....CODE GREY CALLED AND SECURITY CHASED PATIENT AND BROUGHT HER BACK TO HER ROOM. PATIENT HIT SECURITY GUARD IN THE HEAD MULTIPLE TIMES AS HE BROUGHT HER BACK INTO ROOM....ED TECH....AND I TRY TO GIVE SHOT TO PATIENT BUT SHE IS KICKING TOO HARD AND WILL NOT BE STILL. CHARGE NURSE....COMES TO HELP. ONE HOLDS HER TORSO AND THE OTHER GRABS HER LEGS AS THE SHOT IS GIVEN IN LEFT LEG. PT KICKED ME IN STOMACH 3 TIMES DURING THE PROCESS. ..." In each of the above situations, record review revealed Geodon was ordered and administered but did not reveal an order for a physical hold or forced medication.

Interview with MD #8, on 01/27/2021 at 1330 revealed the physician recalled Patient #4. MD #8 stated the only time a patient would be held down would be a true emergency situation for patient and/or staff safety. Interview revealed if a patient was held down for a medication, it was a brief physical hold that only lasted a few seconds. Interview revealed there was no policy on forced medications.

Interview with RN #10, on 01/27/2020 at 1515, revealed forced medication was only used for psych patients under involuntary commitment. Interview revealed if a patient was held down in a physical hold, it was not considered a restraint. The RN stated "they have not told us that (it was a restraint)."

Telephone interview with RN #9, on 01/27/2021 at 1705, revealed Patient #4 was medicated emergently several times. RN #9 stated when a patient was held down for a medication it was not a restraint, it was for safety. Interview revealed a physical hold was not considered a restraint at this hospital.

Interview on 01/28/2020 at 1010 with RN #11 revealed the RN recalled Patient #4 and had cared for her. Interview revealed the patient could be very explosive and physically violent to staff. Interview revealed RN #11 recalled a time when security staff and an ED Tech had been present for medication administration. Interview revealed the patient fought the injection and was physically held to protect her safety. Interview revealed Security also assisted with Code Grays. Interview revealed that neither the policy nor the order sheet mentioned a physical hold as a restraint.

Telephone interview on 01/28/2021 at 1310 with MD #7 revealed the MD recalled Patient #4. MD #7 stated "at times" Patient #4 was held down for medications. Interview revealed the Physician would consider it as forcibly giving the medication, otherwise they would not have needed to hold the patient down. Interview revealed the MD was not sure if a hold was a restraint, as it was brief and helpful for the patient.

Telephone interview with RN #12 on 01/29/2021 at 0845 revealed the RN recalled a day when Patient #4 was running through the halls, then got on the floor and would not get up. Interview revealed Security tried to get the patient up and had his arm under the patient's arm trying to bring her forward. The RN stated she would not consider that hold to be a restraint because they were trying to get the patient back to a safe situation. Interview revealed RN #12 also recalled a time when one person was holding the patient's wrists and hands while RN #12 tried to hold her legs to give an injection. Interview revealed it did not work, the patient was fighting them and the Charge Nurse (CN) came to assist. The CN gave the injection while the other two held the patient. Interview revealed the hold was not considered a restraint. Interview revealed the staff only had orders for soft restraints, there were no orders for holds.

Based on facility policy and procedure review, medical record review, and staff and provider interviews, facility staff failed to identify policy for nursing reassessment frequency for patients in forensic devices, and failed to reassess patients or obtain vital signs per policy for 2 of 7 sampled behavioral health patients. (Patients #1 and #3)

The findings include:

Review of the facility's policy, "NS (Nursing Services) ED (Emergency Department) Patient Continuum" last revised 02/2020 revealed, " POLICY: Establish the links of seamless delivery of healthcare ...Initial assessment of the Emergency Department patient will begin upon presentation to the Emergency Department and reassessment of vital signs will be done at a minimum of q2h and more often as the condition warrants ..."

Review of the facility's policy, "Care of the Psychiatric Patient" last revised 01/2018 revealed, " ...PROCEDURE OR PROCESS: ...Documentation of police custody and restraint must be included in the patient's medical record. A medical screening and mental health evaluations will be completed through a collaborative effort of physicians and nurses ...the patient will remain in the hospital under custodial and protective care of (Named Facility) ..."

Review of policy "... Restraint", last revised 12/2019, revealed "...(Facility Name) will have policies and procedures designed to protect patient rights.... and ensure safety of the patient, staff, and others....Exemptions from requirements of the restraint standards are inclusive of the following...the use of handcuffs or other restrictive devices applied by law enforcement officials....The....monitoring of forensic devices....are the responsibility of law enforcement. ..." Policy review did not reveal documentation requirements related to reassessment of patients in forensic devices.

1. Review of the closed medical record on 01/26/2021/through 01/29/2021 revealed Patient #3 was a 57-year-old female who arrived in the ED on 10/28/2020 at 1927 via emergency medical Services (EMS). Review revealed IVC proceedings had been initiated in the ED on 10/28/2020, Patient #3 received Ativan (medication to treat anxiety disorder) 1 mg (milligram) IV (intravenous, into a vein) at 2032 and the "First Examination For Involuntary Commitment" had been completed by an ED MD, (#3), at 2040. Review of a History and Physical dated 10/28/2020 at 2334 revealed the reason for admission was "Intentional drug overdose." Review of a Nursing note by a registered nurse, RN #1, dated 10/29/20 at 0220 revealed, "Pt (patient) agitated, aggressive, yelling. MD called to bedside to clarify plan of care and IVC. Pt attempting to exit room....pt physically pushing staff and law enforcement ...was handcuffed by law enforcement to stretcher..." Review revealed the following medications were administered on 10/29/2020: Ativan 1 mg IM (intramuscularly) at 0306, Haldol 5 mg IM at 0310, Haldol 5 mg orally at 0348. An Alcohol Withdrawal Order set was initiated on 10/29/2020 at 0348. Geodon 10 mg IM (intramuscular injection) (medication used to reduce agitation) was given to Patient #3 at 0409. Review revealed vital signs were obtained on 10/28/2020 at 2353, 10/29/2020 at 0500 (5 hours and 7 minutes), 10/29/2020 at 0900 (four hours), and 10/29/2020 at 1505 (6 hours and 6 minutes). Review revealed nursing assessments were completed for Patient #3 on 10/29/2020 at 0037 and 0500. Review of the record revealed Patient #3 was transported to an outside inpatient mental health facility under IVC orders by law enforcement officers on 10/29/2020 at 1907.

Review of an internal Patient Safety Event Manager reports dated 10/30/2020 at 1249 revealed, "...At approx. 2 AM Pt awake, combative, fighting with staff, non-directable, police in dept with another pt, heard pt fighting and yelling and attempted to redirect patient. She tried to push past police to leave and would not listen to them...placed in handcuffs by (named) PD (officer)..."

Telephone interview on 01/28/2021 at 0941 with ED RN #1 revealed she had been Patient #3's primary nurse on the evening of her admission. Interview with RN #1 revealed she now believed her documentation that night was "incomplete" and not according to facility policy. Interview revealed RN #1 now believed assessments related patients in forensic restraints and who were given medications used to control behavior should be done for behavioral health patients.

Interview on 01/27/2021 at 1710 with ED RN #2 revealed all restraints, chemical or physical, were expected to be monitored, assessed, and documented by staff.

Interview 01/27/2021 at 1305 with an ED charge nurse, RN #13, revealed, the processes staff used to document care of behavioral health patients while in the ED needed more clarity, and it needed to be "a teamwork effort."

Interview on 01/27/2021 at 1205 with the Director of Nursing, DON, revealed her expectation was that staff continue to monitor and document patient care and assessments as described in policy guidelines even if patients were in forensic restraints applied by law enforcement officers. Interview revealed the application and maintenance of cuffs was police department responsibility, but patient care remained the facility staff's responsibility and it should be evident in documentation.



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2. Closed medical record review on 01/27/2021 revealed Patient #1 was a 31-year-old male who arrived at the Emergency Department via EMS (Emergency Medical Services)on 11/07/2020 at 0055 due to Suicidal Ideations. Review of the Emergency Department (ED) Report dated 11/07/2020 revealed, "History of Present Illness (HPI): ... Patient states that he wishes to harm himself and that places other people in danger around him ... Course: Given suicidal ideation, I will take out IVC (Involuntary Commitment) paperwork. 0101 hours: Patient stood up in the hallway and started to get something out of his bags and then started to act aggressive towards EMS. Patient required law enforcement intervention to be subdued in the ED." Review of the Secondary Assessment dated 11/07/2020 at 0145 revealed, "Pulse Quality: Strong, Neurological symptoms: Suicidal, Neurological Presentation: Alert, Appropriate, Awake, Cooperative, At this time, Speech: Clear .... Skin description: Warm, dry, normal color." Review of Nursing Documentation dated 11/07/2020 at 1056 revealed, " ...(named) PD (Police Department) and sitter outside the door." Review of Psychiatric Note dated 11/07/2020 at 1339 revealed, "HPI. ...hand cuffed to the bed rail; he does not want to answer further questions unless his had is take out of the cuff..." Nursing Documentation dated 11/07/2020 at 2308 revealed, "... resting quietly now. handcuffed to bed deputy at bedside." Review of Patient Notes dated 11/08/2020 at 0715 revealed, "patient lying in bed, hand cuff to bed rail ..." Review of Psychiatric Note dated 11/09/2020 at 1234 revealed, " HPI: ... and is still handcuffed to his bed" Nursing Documentation dated 11/09/2020 at 1810 revealed, "patient resting quietly, officer at doorway ..." Review of the Shift Assessment dated 11/10/2020 at 0929 revealed, "Adult Shift/Focus Assessment, Assessment Type: Shift, ... Cardiovascular WDP(Within Defined Parameters): Y, ... Musculoskeletal WDP: Y, Integumentary WDP: Y, Psychosocial WDP: N, ... Psychosocial Assessment: Affect: Preoccupied, Blunted, Guarded or suspicious, Behavior: Cooperative, Resists care, Appearance: Disheveled, Thought process: Paranoia ..." Review of Patient Notes dated 11/10/2020 at 1155 revealed, "patient had his handcuff switched from right to left hand. The hand cuffs are not tight, no skin break down noted on either wrist. (named) police are outside the door." Review of Patient Notes dated 11/10/2020 at 1241 revealed, "patient is currently out of hand cuffs and in the shower, (named) pd officer, (named facility) security, and (named ER director) are with the patient." Medical record review revealed patient was discharged 11/11/2020 at 1512. Medical record review revealed Patient #1 was handcuffed from 11/07/2020 until 11/10/2020. Medical record review failed to reveal assessment of Integumentary, Musculoskeletal, or Cardiovascular systems on 11/08/2020 and 11/09/2020.

Interview on 01/27/2021 at 1410 with the DON (Director of Nursing) revealed the restraint flowsheet is for hospital applied restraints. Interview revealed patients restrained by law enforcement do not have a different flowsheet for documentation. The DON revealed the safety observation sheets detailed patient behavior of psychiatric patients. Interview further revealed that police presence and police applied restraints were in nursing documentation.

Interview on 01/27/2021 at 1405 with RN (Registered Nurse) # 13 revealed she recalled caring for Patient #1. RN# 13 stated, "(ED staff) not documenting as well as they could be."

Interview on 01/29/2021 at 0850 with RN # 12 revealed she recalled caring for Patient #1. Interview revealed that some ED staff document when police switch handcuffed wrists or skin/pulse assessment of the handcuffed extremity. RN # 12 revealed that ED staff documentation of assessments was inconsistent. Interview revealed RN # 12 failed to receive training on documentation and assessment of patients in handcuffs.

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