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Based on record review and interview the Hospital failed to ensure the use of restraints were in accordance with the order of a physician for 3 Patients (#7, #8, and #6), out of a total sample of 10 patients, and failed to demonstrate a four-point restraint was implemented as ordered by a physician and document a patient's response to the restraint to ensure the immediate physical safety for 1 Patient (#8) out of a total sample of 10 patients

Refer to tags A-0168 and A-0188.

Based on record review and interview the Hospital failed to ensure the use of restraints were in accordance with the order of a physician for 3 Patients (#7, #8, and #6), out of a total sample of 10 patients.

Findings include:

Review of the Hospital policy titled "Restraint and Seclusion", approved 3/11/2020, indicated the following:
-The use of restraint and seclusion is in accordance with written modification to the patient's plan of care.
-A provider order is required for the application of restraint or seclusion. The attending physician or clinical psychologist is consulted as soon as feasible if he/she did not order the restraint or seclusion.
-In some situations, the need for restraint intervention may occur so quickly that an order cannot be obtained prior to the application of the restraint. In these emergency situations, the order must be obtained during the application or as soon as possible after the restraint application.
-The patient's plan of care must be modified to include the use of restraints and/or seclusion.

1. Patient #7 was admitted to the Hospital Emergency Department on 2/23/21 for psychiatric evaluation with a section 12 with a diagnosis of agitation.

Review of Patient #7's medical record indicated after he/she presented to the Emergency Department and requested to be placed in restraints of he/she would become physically violent. On 2/23/22 at 12:56 P.M., Patient #7 was placed in violent restraints. At 3:36 P.M., Patient #7 remained in 4-point restraints. At 5:27 P.M., Patient #7 was in 2-point restraints. On 2/23/22 at 8:00 P.M., Patient #7's restraints were removed.

Further review of Patient #7's medical record failed to indicate orders for the 4-point violent restraints nor the 2-point restraints were ever implemented or written in the Patient's record for the restraints applied to him/her on 2/23/22.

During an interview with Physician #4 on 8/15/22 at 11:25 A.M., he said Patient #7 presented to the Emergency Department with altered mental status. He said the Patient was agitated and stated if he/she wasn't put in restraints, he/she would be violent. Physician #4 said Patient #7 was placed in restraints; he could not recall if the verbal order for restraints was given by himself or the attending physician. Physician #4 said when he gives verbal orders for restraints, he will enter them into the electronic medical record when he can.

During an interview with Nurse #3 on 8/15/22 at 3:05 P.M., she was unable to recall the events involving Patient #7 on 2/23/22. She said Registered Nurses (RN) will notify Physician's if a patient requires restraints for safety. She said Physician's enter the orders for restraints into the electronic medical records.

The Hospital failed to ensure physician orders were in place for physical restraints applied to Patient #7.

2. Patient #8 was admitted to the Hospital Emergency Department on 10/15/21 at 11:24 P.M., with a diagnosis of alcohol intoxication, hyponatremia (low sodium levels) and altered mental status.

Review of Patient #8's Patient Care Timeline indicated he/she presented to the Hospital Emergency Department with concern for alcohol intoxication and was not able to provide any additional history. On 10/16/21 at 2:40 A.M., Nurse #1 documented Patient #8 was placed in non-violent type hard restraints (2-point) to his/her right wrist and left ankle.

Review of Patient #8's medical record failed to indicate any order for 2-point restraints was ever entered into the electronic medical record for the Patient.

During an interview with Physician #3 on 8/16/22 at 1:30 P.M., he said Patient #8 had been admitted to the Emergency Department on 10/15/21 between 11:00 P.M. and 12:00 A.M. Physician #3 said Patient #8 was intoxicated and initially cooperative. Physician #3 said during the early morning on 10/16/21, Patient #8 started to become delirious, was showing signs of alcohol withdrawal, and was moved to bay 28 for safety. Physician #3 said 2-point restraints were applied to Patient #8 for safety and he/she was medicated with Haldol. Physician #3 said Patient #8 was medically unsafe and the restraint measures were necessary to protect the Patient and get his/her apnea under control. Physician #3 acknowledged there had not been an order for 2-point restraints entered for Patient #8 in the electronic medical record.

During an interview with Nurse #1 on 8/16/22 at 2:00 P.M., she said she took on the care for Patient #8 during the early morning of 10/16/21 in the Emergency department. Nurse #1 said Patient #8 became resistive and aggressive while she was attempting to care for him/her. She said she was given a verbal order for 2-point restraints from Physician #3 for Patient #8. Nurse #1 said Patient #8 was impulsive the rest of her shift and was unable to be brought for his/her Computed Tomography (CT) scan until approximately 6 A.M. Nurse #1 said at 7 A.M. her shift ended, and Patient #8 was still in 2-point restraints.

The Hospital failed to ensure physician orders were in place for physical restraints applied to Patient #8.




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3. Record review indicated that Patient #6 was in two-point soft physical restraints on 08/08/2022 and 08/11/2022. The record did not indicate any provider orders entered for Patient #6 for 08/08/2022 and 08/11/2022.

The surveyor interviewed the hospital's compliance specialist on 08/15/2022 at 4:00 P.M. The compliance specialist acknowledged that nursing assessments indicated Patient #6 was in two-point soft physical restraints on 08/08/2022 and 08/11/2022, and no provider orders could be found for those given dates.

Based on record review and interview, the Hospital failed to demonstrate a four-point restraint was implemented as ordered by a physician and document a patient's response to the restraint to ensure the immediate physical safety for 1 Patient (#8) out of a total sample of 10 patients, the Patient experienced cardiac arrest and ultimately expired in the Hospital Emergency Department.

Findings include:

Patient #8 was admitted to the Hospital Emergency Department on 10/15/21 at 11:24 P.M., with a diagnosis of alcohol intoxication, hyponatremia (low sodium levels) and altered mental status.

Review of the Hospital policy titled "Restraint and Seclusion", approved 3/11/2020, indicated the following:
-A provider order is required for the application of restraint or seclusion. The attending physician or clinical psychologist is consulted as soon as feasible if he/she did not order the restraint or seclusion.
-An order is active until it expires or is discontinued by a provider. A new episode begins when the type of number of restraints changes or after an order has been discontinued.
-The Registered Nurse (RN) must notify a provider that the restraint was discontinued as soon as it is appropriate and no later than the end of shift.
-Violent restraint orders require a documented face to face assessment of the patient's physical/medical and psychological status within one hour of the initial restraint application and every subsequent restraint application.
-The RN shall assess and document the following at least once per shift for all restraints: clinical justification, alternative or less restrictive interventions attempted, discontinuation criteria, patient response, type and location for restraint device.
-Patient assessments and reassessments shall be conducted every 15 minutes. The performance of any of restraint monitoring shall be documented at least once per shift when applicable.

Review of Patient #8's Patient Care Timeline indicated he/she presented to the Hospital Emergency Department with concern for alcohol intoxication and was not able to provide any additional history. On 10/16/21 at 2:40 A.M., Nurse #1 documented Patient #8 was placed in non-violent type hard restraints (2-point) to his/her right wrist and left ankle. Around 2:45 A.M. Patient #8 became increasingly agitated and was moved to a bay for situational control; the Patient seemed delirious and there was concern for acute alcohol withdrawal. At 3:04 A.M. Patient #8 received a 5mg (milligram) dose of Haldol (antipsychotic medication) intramuscularly. At 5:45 A.M., Patient #8 received another 2.5mg of Haldol intravenously, followed by another 2.5mg of Haldol intravenously at 5:46 A.M., and at 5:47 A.M. was restless and in 2-point restraints. On 10/16/21 at 8:11 A.M., an order was placed by Physician #2 for Restraints-Adult Violent/Self Destructive Restraint, 4-point (one to each extremity) for the reason of imminent substantial risk of serious self-harm. At 8:23 A.M., the order for the 4-point restraints to Patient #8 was acknowledged by Nurse #2, and the order was acknowledged again by Nurse #2 at 9:17 A.M. On 10/16/22 at 10:30 A.M., Nurse #2 documented Patient #8 removed his/her own peripheral IV (intravenous) device and was redirected back to bed by another Nurse. At 11:20 A.M. Physician #1 discontinued the initial 4-point restraint order, and reordered the 4-point restraint for Patient #8 for the reason of imminent substantial risk of serious self-harm. At 11:58 A.M., Patient #8 was found out of his/her bed by Nurse #2, redirected back to bed by Nurse #2, and subsequently found unresponsive and pulseless by Nurse #2 2-3 minutes later; Cardiopulmonary Resuscitation (CPR) was initiated. A new IV device was placed in Patient #8's right antecubital at 12:07 A.M. after an unsuccessful attempt at 12:06 A.M. Ultimately, compressions/CPR efforts were stopped at 12:49 P.M. and Patient #8 expired.

Review of Patient #8's medical record failed to indicate any documentation of restraint assessment of Patient #8 or implementation of 4-point restraints to the Patient following the initial order for 4-point restraints by Physician #2 on 10/16/21 at 8:11 A.M. Subsequently, Patient #8's medical record failed to indicate any documentation of restraint assessment of Patient #8 or implementation of 4-point hard restraints to the Patient following the order for 4-point restraints by Physician #1 on 10/16/21 at 11:20 A.M. Patient #8 was ordered to have 4-point restraints from 8:11 A.M. until his/her demise at 12:49 P.M. on 10/16/21; during this period Patient #8 was able to remove his/her peripheral IV device and get out of bed twice despite being ordered to be restrained due to imminent substantial risk of serious self-harm. Despite the order for 4-point restraints Patient #8 being acknowledged twice by Nurse #2, the Hospital failed to produce an assessment of the Patient's reaction to the 4-point restraint intervention; Patient #8's medical record also failed to indicate the Patient had ever been placed in 4-point restraints, removed from 4-point restraints, nor was the order ever clarified with a physician/provider. Review of Physician #2's note dated 10/26/22 at 11:24 A.M., failed to indicate anything regarding Patient #8 removing his/her peripheral IV device nor getting out of his/her bed at 10:30 A.M, despite orders being in place for 4-point restraints.

Review of the Hospital's investigation of the events involving Patient #8 on 10/15/21 - 10/16/21 included a conversation documented with Nurse #2. Nurse #2 reported at the start of his shift, Patient #8 had been in 2-point leather restraints, but those had been removed related to the patient being somnolent. The documented conversation with Nurse #2 failed to indicate any mention of the use of 4-point restraints.

During an interview with Physician #3 on 8/16/22 at 1:30 P.M., he said Patient #8 had been admitted to the Emergency Department on 10/15/21 between 11:00 P.M. and 12:00 A.M. Physician #3 said Patient #8 was intoxicated and initially cooperative. Physician #3 said during the early morning on 10/16/21, Patient #8 started to become delirious, was showing signs of alcohol withdrawal, and was moved to bay 28 for safety. Physician #3 said 2-point restraints were applied to Patient #8 for safety and he/she was medicated with Haldol. Physician #3 said Patient #8 was medically unsafe and the restraint measures were necessary to protect the Patient and get his/her apnea under control.

During an interview with Nurse #1 on 8/16/22 at 2:00 P.M., she said she took on the care for Patient #8 during the early morning of 10/16/21 in the Emergency department. Nurse #1 said Patient #8 became resistive and aggressive while she was attempting to care for him/her. She said she was given a verbal order for 2-point restraints from Physician #3 for Patient #8. Nurse #1 said Patient #8 was impulsive the rest of her shift and was unable to be brought for his/her Computed Tomography (CT) scan until approximately 6 A.M. Nurse #1 said at 7 A.M. her shift ended and Patient #8 was still in 2-point restraints.

During an interview with Physician #1 on 10/17/21 at 10:00 A.M., he said he was assuming the care of Patient #8 on the morning of 10/16/21. Physician #1 said Patient #8 was somnolent during his initial face-to-face interview with the Patient; he had received in pass-off/report that Patient #8 had required chemical/physical restraints on the overnight shift. Physician #1 said another physician had placed an order for the 4-point restraints, and he continued the order when entering admission orders for Patient #8. Physician #1 said he continued the order for the 4-point restraints for Patient #8 because there was a concern the Patient would remove his/her oxygen as he/she had been pulling at his/her nasal cannula tubing. Physician #1 was unable to recall if Patient #8 had been in 4-point restraints.

The Hospital failed to demonstrate a four-point restraint was implemented for a Patient with imminent substantial risk of serious self-harm as ordered by a Physician, and failed to produce any documentation of the Patient's response to the restraint.

Based on record review and interview, the Hospital failed to identify opportunities for improvement and changes that will lead to improvement through data collected for 1 Patient (#8) who was ordered to be restrained due to imminent substantial risk of serious self-harm, experienced cardiac arrest and ultimately expired in the Hospital Emergency Department out of a total sample of 10 patients.

Refer to tag A-0283

Based on record review and interview, the Hospital failed to identify opportunities for improvement and changes that will lead to improvement through data collected for 1 Patient (#8) who was ordered to be restrained due to imminent substantial risk of serious self-harm, experienced cardiac arrest and ultimately expired in the Hospital Emergency Department out of a total sample of 10 patients.

Findings include:

Patient #8 was admitted to the Hospital Emergency Department on 10/15/21 at 11:24 P.M., with a diagnosis of alcohol intoxication, hyponatremia (low sodium levels) and altered mental status.

Review of the Hospital Quality and Patient Safety Plan, dated 3/6/2020, indicated the following:
-The service Quality Assessment Committee and infrastructure shall evaluate the (safety) reports and coordinate with the Chair of QPSC as to appropriate follow-up.

Review of Patient #8's Patient Care Timeline indicated he/she presented to the Hospital Emergency Department with concern for alcohol intoxication and was not able to provide any additional history. On 10/16/21 at 2:40 A.M., Nurse #1 documented Patient #8 was placed in non-violent type hard restraints (2-point) to his/her right wrist and left ankle. Around 2:45 A.M. Patient #8 became increasingly agitated and was moved to a bay for situational control; the Patient seemed delirious and there was concern for acute alcohol withdrawal. At 3:04 A.M. Patient #8 received a 5mg (milligram) dose of Haldol (antipsychotic medication) intramuscularly. At 5:45 A.M., Patient #8 received another 2.5mg of Haldol intravenously, followed by another 2.5mg of Haldol intravenously at 5:46 A.M., and at 5:47 A.M. was restless and in 2-point restraints. On 10/16/21 at 8:11 A.M., an order was placed by Physician #2 for Restraints-Adult Violent/Self Destructive Restraint, 4-point (one to each extremity) for the reason of imminent substantial risk of serious self-harm. At 8:23 A.M., the order for the 4-point restraints to Patient #8 was acknowledged by Nurse #2, and the order was acknowledged again by Nurse #2 at 9:17 A.M. On 10/16/22 at 10:30 A.M., Nurse #2 documented Patient #8 removed his/her own peripheral IV (intravenous) device and was redirected back to bed by another Nurse. At 11:20 A.M. Physician #1 discontinued the initial 4-point restraint order and reordered the 4-point restraint for Patient #8 for the reason of imminent substantial risk of serious self-harm. At 11:58 A.M., Patient #8 was found out of his/her bed by Nurse #2, redirected back to bed by Nurse #2, and subsequently found unresponsive and pulseless by Nurse #2 2-3 minutes later; Cardiopulmonary Resuscitation (CPR) was initiated. A new IV device was placed in Patient #8's right antecubital at 12:07 A.M. after an unsuccessful attempt at 12:06 A.M. Ultimately, compressions/CPR efforts were stopped at 12:49 P.M. and Patient #8 expired.

Review of Patient #8's medical record failed to indicate any documentation of restraint assessment of Patient #8 or implementation of 4-point restraints to the Patient following the initial order for 4-point restraints by Physician #2 on 10/16/21 at 8:11 A.M. Subsequently, Patient #8's medical record failed to indicate any documentation of restraint assessment of Patient #8 or implementation of 4-point hard restraints to the Patient following the order for 4-point restraints by Physician #1 on 10/16/21 at 11:20 A.M. Patient #8 was ordered to have 4-point restraints from 8:11 A.M. until his/her demise at 12:49 P.M. on 10/16/21; during this period Patient #8 was able to remove his/her peripheral IV device and get out of bed twice despite being ordered to be restrained due to imminent substantial risk of serious self-harm. Despite the order for 4-point restraints Patient #8 being acknowledged twice by Nurse #2, the Hospital failed to produce an assessment of the Patient's reaction to the 4-point restraint intervention; Patient #8's medical record also failed to indicate the Patient had ever been placed in 4-point restraints, removed from 4-point restraints, nor was the order ever clarified with a physician/provider. Review of Physician #2's note dated 10/26/22 at 11:24 A.M., failed to indicate anything regarding Patient #8 removing his/her peripheral IV device nor getting out of his/her bed at 10:30 A.M, despite orders being in place for 4-point restraints.

Review of the Hospital's Nursing- Emergency Department investigation of the events involving Patient #8 on 10/15/21 - 10/16/21 included the following:
-A brief factual description which reviewed CPR and other measures applied after Patient #8 experienced cardiac/pulmonary arrest.
-Lack of IV (intravenous) access
-Delay in overall patient care
-Suggestions for improvement included having IV access and training for nursing staff on management of codes.
-A timeline of Patient #8's care, which included the Patient being found out of bed and removing his/her own peripheral IV device at 10:30 A.M. and getting out of bed again at 11:58 A.M. on 10/16/21 prior to being found unresponsive and pulseless 2-3 minutes later.
-A documented conversation with Nurse #2 which indicated Patient #8 had gotten out of bed and removed his/her peripheral IV device and was not replaced by Nurse #2.

Review of the Hospital's Emergency Services - Boarder investigation of the events involving Patient #8 on 10/15/21 - 10/16/21 included the following:
-A brief description of the event from when Patient #8 was discovered unresponsive and cyanotic in bed.
-No attending was present during the code/CPR or Patient #8
-Staff felt there was a lack of training and exposure to events such as Patient #8's
-Suggestions for improvement included more education for code initiation for all staff, and designating 4th years (physician) to be assigned to respond to emergencies.
-Patient #8's record was reviewed.

Both the Nursing- Emergency Department and Emergency Services - Boarder investigations of the events involving Patient #8 on 10/15/21 - 10/16/21 failed to identify while Patient #8 was ordered to be restrained by 4 point restraints on 10/16/21, there was no evidence in his/her medical record that he/she ever was restrained while the orders for restraints were active. The timeline generated during the Nursing - Emergency Department investigation failed to ever identify the 2 orders for 4-point restraints entered into Patient #8's electronic medical record. Despite IV access being identified as an issue during the code and CPR of Patient #8, the Hospital failed to identify during record review that Patient #8 had removed his/her own peripheral IV device and got out of bed while he/she was ordered to be restrained due to imminent substantial risk of serious self-harm.

During an interview with the Chief Compliance Officer on 8/16/22 at 10:15 A.M., he said Patient #8's restraints were not reviewed during the Hospital investigation on 10/15/21 - 10/16/21 because the focus of the investigation was on the Patient's code/CPR.

During an interview with Physician #1 on 10/17/21 at 10:00 A.M., he said he was assuming the care of Patient #8 on the morning of 10/16/21. Physician #1 said Patient #8 was somnolent during his initial face-to-face interview with the Patient; he had received in pass-off/report that Patient #8 had required chemical/physical restraints on the overnight shift. Physician #1 said another physician had placed an order for the 4-point restraints, and he continued the order when entering admission orders for Patient #8. Physician #1 said he continued the order for the 4-point restraints for Patient #8 because there was a concern the Patient would remove his/her oxygen as he/she had been pulling at his/her nasal cannula tubing. Physician #1 was unable to recall if Patient #8 had been in 4-point restraints.

The Hospital failed to identify opportunities for improvement with management of patient restraints and changes that will lead to improvement for patient care during the record review and investigation a Patient #8's admission to the Emergency Department on 10/15/22 - 10/16/22.