HospitalInspections.org

Based on medical record review, interviews and review of policy and procedure, the hospital failed to assure Patient Identifier (PI) # 1, a patient who was not in the custody of law enforcement, was assessed for the least restrictive, hospital approved restraint due to PI # 1's self destructive / violent behavior exhibited on 10/18/14. The hospital also failed to obtain a physician's order for restraints and monitor PI # 1 for:
- signs of injury related to restraint application,
- Nutrition / Hydration,
- Circulation, Range of Motion...
- Hygiene and elimination...and
- Maintenance of the patient's rights, dignity and safety...while the patient was restrained in handcuffs, a non-clinical, non hospital approved restraint by a Corrections Officer.

Findings Include:

Refer to A-154 and A-168

This deficient practice affected PI # 1 and had the potential to affect all other patients requiring the use of restraint.

Based on medical record review, policy and procedure review and interviews, hospital staff failed to appropriately assess Patient Identifier (PI) # 1 for hospital approved restraint use due to self destructive / violent behavior exhibited by the patient on 10/18/14. Although PI # 1's behavior escalated throughout the day, staff failed to consider restraint as a clinical intervention. Instead, staff allowed a corrections officer, responsible for guarding another patient (in custody of officer), to place handcuffs on PI # 1, a patient not in the officer's custody. The hospital also failed to monitor PI # 1 at established timeframes while the patient was restrained. This affected PI # 1, one of ten sampled patients who required restraint.

Findings Include:

1). Review of PI # 1's Emergency Department (ED) Medical Record:

Nurse's Notes:
10/17/14 at 23:28: Presenting complaint: EMS (Emergency Medical Services) states patient took 5200 mg. (milligrams) of Lyrica (medication indicated for the management of: Fibromyalgia, Neuropathic pain associated with Diabetic Peripheral Neuropathy, Postherpetic Neuralgia and
Neuropathic pain associated with Spinal Cord Injury (obtained from www.Pfizer.com)....IV (intravenous) line initiated by EMS.

Triage: 10/17/14 at 23:32: Complains of pain in head...in no apparent distress...

10/17/14 at 23:35: ...Awake, obeys commands, Oriented to time, place, person, situation...drowsy...speech is slurred...

10/17/14 at 00:18: Pt. (patient) started actively seizing. MD (Medical Doctor)notified...

10/17/14 at 00:20: Respiratory called to place pt. on bi-pap (Bilevel positive airway pressure - a method of respiratory ventilation that uses an electronic circuit to monitor breathing by providing two different pressures, a higher one during inhalation and a lower pressure during exhalation via a facemask that fits over the nose and mouth and forces air through the passages or blows the airways open during sleep. Information obtained from www.sleepdisordersguide.com/topics/bipap).

10/18/14 at 01:19: Pt. has started jerking randomly again. Remains unresponsive. MD at bedside and orders for Ativan received. Given 1 mg. Ativan IVP (Intravenous push).

10/18/14 at 02:14: No seizure activity noted...Unresponsive. Remains on bi-pap...

10/18/14 at 02:16: Admit to Intensive Care Unit (ICU)... patient unresponsive.


ED Physician Documentation:

10/18/14 at 00:40: Preliminary Diagnoses: Drug Overdose, Seizure Epileptic... Condition is guarded...


ICU Medical Record Documentation:

10/18/14 0225 - 0255: Admitted from ED to ICU. Unresponsive. BiPAP with Oxygen. Urethral Catheter...IV in left hand...Observer at bedside due to suicide precautions. (Documented by RN (Registered Nurse) assigned to PI # 1: 07:00 - 19:00)


10/18/14 at 0730: ...Awake...slurred speech. Pt. (PI # 1) states...he/she wants to die. Pt. states...will try again once he/she leaves the hospital... Foley catheter in place... BiPAP replaced with 2 L (Liters) NC (Nasal Cannula). Saturation 100%... (RN assigned to PI # 1: 07:00 - 19:00)


10/18/14 at 0900: Pt..volatile and very aggressive...States he/she is getting angry...does not want to be here...On attempt to let pt. stretch his/her legs... could not stand with assist and was returned to bed...Reoriented to time and place...(RN assigned to PI # 1: 07:00 - 19:00)

Mental Health Therapy Note - 10/18/14 09:37: ...Seen at Dekalb Regional Medical Center for an overdose and suicidal ideations with a plan and intent to kill (self)...reports visual hallucinations...Therapist recommends inpatient services for safety and further evaluation...contacted (name of Mental Health staff) to issue a hold order due to numerous attempts made by patient to leave the hospital.

10/18/14 at 10:00: Mental Health (MH) at bedside for evaluation. Inpatient treatment recommended. Second MH personnel to bedside with hold order placed. ...(RN assigned to PI # 1: 07:00 - 19:00)


10/18/14 at 12:00: Pt. states he/she must go home to...son's grave...Very erratic and emotional. States he/she will do whatever it takes to leave here...(RN assigned to PI # 1: 07:00 - 19:00)


10/18/14 at 14:00: Pt. pulls IV out. Bleeding stopped. Bandage placed.
Pt. acting very violent. Stating he/she is going to leave and nobody can stop him/her...says...can do whatever he/she wants to self and it is nobody's business...(Abbreviation for Local Police Department - PD) arrives due to pt. hold order...Pt. family acting erratic...Stating nobody can hold their (family member - PI # 1)...PD escorted family off hospital property. Pt...attempts to get up...gait not steady...remains non-ambulatory. Foley intact...Pt. throws things within reach at wall...Attempts to calm pt. are ignored. (RN - assigned to PI # 1: 07:00 - 19:00).


10/18/14 at 14:00 (Documented by ICU Director): ...Received notification that (PD) had been called by ICU Charge Nurse to assist with a situation in ICU. Hospital staff overheard patient's mother saying that she was going to break PI # 1 out of ICU by taking him/her out of the back door and down the stairs with his/her catheter. She was also overheard saying that PI # 1 should punch hospital staff in the face so he/she could get out of here. Staff concerned that family would attempt to remove pt. from the unit at the next visit and/or provoke violence against hospital staff. For theses reasons (PD) was called to assist. Officers offered to speak with patient...to calm and encourage pt. to stay. Pt. was verbally abusive towards officers....very labile...Both officers and I attempted to calm pt...explained to pt. that he/she was under a court hold and he/she would be transferred to a mental health facility when placement obtained. Patient's telephone was removed from...room due to pt. using it to plan escape with family...


10/18/14 at 19:15: Pt. (PI # 1) took all monitors off. Refused assessment. Pt. asked to use phone (prohibited due to calling family to plan escape from hospital). When pt. was informed...became angry. Attempted to leave the hospital against court hold..."Threats" nurses...called Nurse Supervisor...to assist with pt. (Documented by ICU staff RN assigned to PI # 1 19:00 - 07:00).


10/18/14 at 19:15: Approximately 19:15 received notification that patient (PI # 1) was attempting to leave hospital...Entered room to find patient hostile, shouting at staff, aggressive towards staff...Pt. refused to return to bed and lunged at staff. (Name of Sheriff's Office Correctional Officer) was present in unit and came to help. I attempted to convince pt. to return to
bed...Pt. refused and said he/she was going home. Pt. again came at staff in a threatening manner. Corrections officer intervened and attempted to deescalate patient. I explained to pt. that he/she had the option of allowing us to take care of him/her here where he/she could move around freely or being restrained and possibly going to jail. I attempted to explain that he/she was interfering with the care of other patients by disturbing their rest. Pt. mood continued to be labile and all attempts at reasoning with pt. failed. Two other patients had complained about the noise from this pt. yelling at staff. Pt. continued to be unreasonable...Shouting and cursing at staff and officer. Pt. came at staff again and officer placed pt. in handcuff. Pt. became uncontrollable and fought officer. Officer and 4 RN's...able to safely return the pt. back to bed while PI # 1 attempted to hit and kick us. Pt. kicked the foot of the bed so hard it broke. Officer attached handcuff on right wrist to upper bedrail on that same side. I asked officer to verify that it was not too tight and he confirmed that it was appropriately placed...(Documented by ICU Director)

10/18/14 at 20:00: Pt. refused to wear monitors. States he/she wants to go to jail...does not want to stay in the hospital. Law enforcement has been called to transport pt. to jail. Dr. (Last name of attending physician) has medically cleared pt...nurse sitting at bedside. (RN assigned to PI # 1 - 19:00 - 07:00).


10/18/14 at 20:30: "Approximately 20:30 Corrections Officer removed handcuff corporal restraint at his discretion due to pt. (PI # 1) being cooperative...Officer states they (Sheriff's Department) unable to take pt. into custody because he/she doesn't have any charges. PD cannot take pt. for the same reason. Spoke with judge who issued the hold order...Judge states Sheriff's Office would only be able to take pt. into custody briefly until psychiatric placement found. Per case management, psychiatric facilities contacted do not have beds available or will not accept until pt. has been in this facility for a minimum of 24 hours." (Documented by ICU Director)

10/18/14 at 23:58: Pt. refuses nursing assessment, refuses monitor and BP (Blood Pressure) cuff. Resting in bed...calm at this time. Guard (hospital observer responsible for suicide monitoring - not working as security staff)at bedside.... Mood very labile. Calm, but escalates to anger very quickly when all requests are not granted.... (Documented by ICU RN assigned to PI # 1 19:00 - 07:00)


A review of PI # 1's Suicide Risk / Behavioral Disorder Assessment for the Non-Behavioral Health Setting revealed:

Level 1 Definition: Requires immediate life saving intervention.
Immediate danger to self or others.

Observed: Violent behavior

Reported: Behavior that has resulted in harm to self or others, including actual suicide attempt

Interventions: Continuous visual surveillance 1:1 ratio. Direct observation by staff ay all times. Must be able to respond to patient immediately...

Fifteen minute suicide checks were imitated on 10/18/14 at 06:45 and discontinued at 12:45 on 10/19/14 that indicated the presence of the guard/observer and what the patient was doing based on observation codes. Example: 21, 11 b = Guard present, sleeping ).

There was no documentation in the medical record documenting that an RN assessed the patient at "established timeframes, as appropriate for the type of restraint," according to hospital policy and procedure (Restraint and Seclusion #: DK-TX-136.00 - see below for details) to include:

1. Signs of injury related to restraint application

2. Nutrition / Hydration

3. Circulation, Range of Motion...

4. Hygiene and elimination...and

5. Maintenance of the patient's rights, dignity and safety...


Probate Court...The Temporary Commitment of (first and last name of PI #1):

Review of the "Temporary Commitment Order dated 10/19/14 revealed
PI # 1 posed a real and present threat of danger to self or to others, and that the threat of danger has been evidenced in that, "Danger to self/others. Please hold for further evaluation. Ordered that Sheriff / Ambulance take the said Respondent into custody and arrange transportation to (name of Psychiatric Hospital). Authorized and Ordered by (Probate Judge's name)."


2). Hospital Policy and Procedure:

Title: Restraint and Seclusion #: DK-TX-136.00

Effective: 1/1/97 Approval: 2/27/14

Definitions:

Restraint: Any physical or mechanical device, material, medication or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.

Instances Where Restraint and Seclusion Standards Do Not Apply:

...G...Correction restrictions for security purposes. The use of handcuffs...applied by law enforcement officials is for custody, detention and public safely reasons, and is not involved in the provision of health care. Therefore, the use of restrictive devices applied and monitored by law enforcement is not a restraint.


Type of Restraint:

A restraint is either a Non-violent, Non-Self destructive or Violent / Self Destructive Behavior restraint.

Violent / Self Destructive Behavioral Reasons for the use of restraint:

...To manage violent or self destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others

Policy:

A. It is the policy of the facility to:

i. Protect the patient and preserve the patient's rights, dignity and well being during restraint use...

ii. Prevent, reduce and eliminate the use of restraints by basing use on the patient's assessed needs:

...c. Limiting the use of restraints...to emergencies where there is a risk to the patient harming self or others. Though patients have the right to refuse treatment, under certain circumstances, if serious bodily harm is judged to be imminent (e.g. violent patient) and RN, after assessment of the patient should institute, which he/she believes will protect the patient and/or others effectively, but alternatives must be considered...

iv. Monitor and meet the patient's need while in restraints;

viii. When the patient is awaiting transfer to a psychiatric unit...if the patient is in restraint...medical or surgical services staff collaborate with psychiatric staff to ensure appropriate evaluation of the patient until transfer occurs.

E. Orders for Restraint

i. The physician...responsible for the care of the patient is authorized to order a restraint...Orders should:

a. Be for each use of the restraints and related to a specific episode of the patient's behavior...

ii. In an emergency application situation, a RN who has documented Restraint...competency may initiate the application of restraint...prior to obtaining an order from an Licensed Independent Practitioner...the order must be obtained during the emergency application or immediately (within a few minutes) after the restraint..has been applied...

H. Periodically Assessing, Assisting and Monitoring the Patient in Restraint...

When restraints...are used there is an increased need for patient monitoring and assessment to assure patient safety, that the least restrictive methods are used when possible, and use is discontinued as soon as possible...

i. "The LIP (Licensed Independent Practitioner) responsible for the patient in person within one hour of the initiation of restraint...used for violent or self destructive behavior. A RN...with a documented competency may perform the in person evaluation within one hour."

ii. When the in person evaluation is performed by the RN...he/she consults with the LIP responsible for the patient as soon as possible.

iii. The in person evaluation must include:

a. An evaluation of the patient's immediate situation.
b. The patient's reaction to the intervention.
c. The patient's medical and behavioral condition.
d. The need to continue or terminate the restraint..."

iv. Immediately after restraints are applied, a qualified RN makes an assessment to ensure restraints were:
a. Properly and safely applied.
b. Applied so as not to cause patient harm or pain.

v. A qualified RN must assess the patient at established timeframes. Assessment...includes:

a. Signs of injury associated with the application of restraints...
b. Nutrition/hydration.
c. Circulation and range of motion in the extremities.
d. Vital signs.
e. Hygiene and elimination.
f. Physical and psychological status and comfort...
i. Ongoing monitoring is performed...includes,but is not limited to the physical and emotional well being of the patient...

L. Documentation:

Each episode of restraint is documented in the patient's medical record...

i. Circumstances and patient's...symptoms that led to restraint use, description of patient's behavior...

iii. Rationale for the type of interventions selected...
v. Written orders for use...
x. All assessments and monitoring of the patient...


3). Interviews:

During an interview on 10/31/14 at 3:20 PM, the ICU Director, Employee Identifier / EI # 1, stated PI # 1 was in ICU Room X. A Corrections Officer was guarding another patient (in custody of law enforcement) also in ICU. PI # 1 had a court order for a hold. According to the Director, the use of restraints was discussed with PI # 1's Attending Physician. However, no documentation was found in the medical record regarding this discussion. A verbal order for Geodon injection, obtained from PI # 1's Attending Physician, was documented on 10/18/14 at 21:54. However, no physician order for mechanical restraint was found in PI # 1's medical record.

According to the Director, restraint use was discussed after PI # 1 was released from the handcuff. Staff determined PI # 1 did not meet criteria for restraint nor was PI # 1 demonstrating behavior that indicated Geodon was needed. No Geodon was administered and no restraint was initiated for PI # 1 after the handcuff was removed.

During an interview on 10/31/14 at 3:20 PM, the ICU Director, Employee Identifier / EI # 1, was asked how staff would have managed PI # 1's behavior if the corrections officer had not been present. The Director replied, "we would have put soft restraints on...at 7:00 PM."

During an interview on 10/30/14 at 7:15 AM, the ED RN assigned to PI # 1 beginning at 19:00 on 10/18/14, stated PI # 1 asked to use the telephone and was told no due to the plan (overheard by staff) between PI # 1 and his/her family to help PI # 1 "escape" from the hospital. The RN said she re-emphasized PI # 1's court hold. PI # 1 got very angry, was shouting and again asked for the telephone. PI #1, "Started coming at me." The observer (staff in room to monitor patient's suicidal behavior) stepped in front of PI # 1, but did not touch him/her. The patient pointed his/her finger at the observer and asked what are you going to do about it?" The RN stated she told a staff person to call the "cops" and the ICU Director. PI # 1 said, "I just want to go to jail...they'll give me my phone." PI # 1 said he/she needed to talk to his/her mother because he/she was afraid Mom was going to kill herself..."

A Correctional Officer (located near to PI # 1's room in ICU who was guarding a patient in custody of law enforcement) came in PI # 1's room. PI # 1 was kicking at staff. "We called Dr. (last name of PI # 1's Attending Physician) who verified PI # 1 was medically stable and could be released to jail. According to the RN / EI # 2, the physician also gave approval for behavioral restraints. (There is no order or documentation about restraints in the medical record). The "cops" were on their way. The officer cuffed the patient to the bed - right arm to upper rail." (bed rail) The officer called the Sheriff's Department and was told no officer was immediately available, but they would send an officer as soon as possible. The RN said she called the local Police Department and was told no officer was available. EI # 2 said, "We have to do something different. I knew we could not leave PI # 1 cuffed if...was not going to jail."

The RN / EI # 2 said she talked to PI # 1 who was now calm and stated he/she no longer wanted to go to jail. The RN removed the hand cuffs and stated there was no rationale for behavioral restraints. The RN stated she checked PI # 1's wrist several times to make sure the cuffs were not hurting the patient. "We call the law. (PI # 1) was intentionally trying to hurt us." PI # 1 was held in cuffs briefly until police arrived to escort the patient to jail. Several staff members were required to get PI # 1 in bed. PI # 1 was kicking so hard...broke the foot of the bed. "If I thought PI # 1 was staying I would have made sure we put restraints." The RN stated she called the Sheriff's Department and was told no officer would come to the hospital unless charges were to be pressed against PI # 1. According to the RN/ EI # 2, thought the Sheriff's Correctional Officer was taking control of PI # 1 until a Sheriff arrived. EI # 2 said, "When I realized PI # 1 was not going to jail I realized things could not continue to be that way-cuffs."

Summary: PI # 1 was not in the custody of the Corrections Officer who applied hand cuffs when PI # 1 attempted to leave the hospital against the court order and was physically aggressive with staff on 10/18/14. Hospital staff assessed PI # 1 for restraint use after the handcuffs were removed. According to hospital restraint policy and procedure, PI # 1 should have been assessed for the use of restraint based on self destructive/violent behavior when other interventions and attempts to reason with the patient failed. Hand cuffs were initiated by a Corrections Officer responsible for a hospital patient who was in custody, not PI # 1. The hospital, not the officer, was responsible for the care and safety of PI # 1.

Based on medical record review, policy and procedure review and interviews, hospital staff failed to obtain a Physician's Order for physical restraint of Patient Identifier (PI) # 1 on 10/18/14 when the patient exhibited self destructive and violent behavior. This affected one of ten sampled patients who required restraint.

Findings Include:

ICU Intensive Care Unit (ICU) Medical Record Documentation:

10/18/14 0225 - 0255: Admitted from ED (Emergency Department) to ICU. Unresponsive. BiPAP with Oxygen. Urethral Catheter...IV (intravenous) in left hand...Observer at bedside due to suicide precautions. (Documented by RN (Registered Nurse) assigned to PI # 1: 07:00 - 19:00)


10/18/14 0730: ...Awake...slurred speech. Pt. (PI # 1) states...he/she wants to die. Pt. states...will try again once he/she leaves the hospital...Foley catheter in place...BiPAP replaced with 2 L (Liters) NC (Nasal Cannula). Saturation 100%... (RN assigned to PI # 1: 07:00 - 19:00)


10/18/14 0900: Pt..volatile and very aggressive...States he/she is getting angry...does not want to be here...(RN assigned to PI # 1: 07:00 - 19:00)

Mental Health Therapy Note - 10/18/14 09:37: ...Seen at Dekalb Regional Medical Center for an overdose and suicidal ideations with a plan and intent to kill (self)...reports visual hallucinations...Therapist recommends inpatient services for safety and further evaluation...contacted (name of Mental Health staff) to issue a hold order due to numerous attempts made by patient to leave the hospital.


10/18/14 12:00: Pt. states he/she must go home to...son's grave...Very erratic and emotional. States he/she will do whatever it takes to leave here...(RN assigned to PI # 1: 07:00 - 19:00)


10/18/14 14:00: Pt. pulls IV out. Bleeding stopped. Bandage placed. Pt. acting very violent. Stating he/she is going to leave and nobody can stop him/her...says...can do whatever he/she wants to self and it is nobody's business...(Abbreviation for Local Police Department - PD) arrives due to pt. hold order...Pt. family acting erratic...Stating nobody can hold their (family member - PI # 1)...PD escorted family off hospital property. Pt...attempts to get up...gait not steady...remains non-ambulatory...Pt. throws things within reach at wall...Attempts to calm pt. are ignored. (RN - assigned to PI # 1: 07:00 - 19:00).


10/18/14 14:00 (Documented by ICU Director): ...Received notification that (PD) had been called by ICU Charge Nurse to assist with a situation in ICU. Hospital staff overheard patient's mother saying that she was going to break PI # 1 out of ICU...Also overheard saying that PI # 1 should punch hospital staff in the face so he/she could get out of here. Staff concerned that family would attempt to remove pt. from the unit at the next visit and/or provoke violence against hospital staff. For theses reasons (PD) was called to assist...Pt. verbally abusive towards officers....very labile...Both officers and I attempted to calm pt...explained to pt. that he/she was under a court hold and he/she would be transferred to a mental health facility when placement obtained. Patient's telephone was removed from...room due to pt. using it to plan escape with family...


10/18/14 19:15: ...Pt. asked to use phone (prohibited due to calling family to plan escape from hospital). When pt. was informed...became angry. Attempted to leave the hospital against court hold..."Threats" nurses... (Documented by ICU staff RN assigned to PI # 1 19:00 - 07:00).


10/18 19:15: Approximately 19:15 received notification that patient (PI # 1) was attempting to leave hospital...Entered room to find patient hostile, shouting at staff, aggressive towards staff...Pt. refused to return to bed and lunged at staff. (Name of Sheriff's Office Correctional Officer) was present in unit and came to help. I attempted to convince pt. to return to
bed...Pt. refused and said he/she was going home. Pt. again came at staff in a threatening manner...I explained to pt. that he/she had the option of allowing us to take care of him/her here where he/she could move around freely or being restrained and possibly going to jail...Pt. mood continued to be labile and all attempts at reasoning with pt. failed...Pt. continued to be unreasonable...Shouting and cursing at staff and officer. Pt. came at staff again and officer placed pt. in handcuff. Pt. became uncontrollable and fought officer...


10/18/14 20:30: "Approximately 20:30 Corrections Officer removed handcuff corporal restraint at his discretion due to pt. (PI # 1) being cooperative..."(Documented by ICU Director)


Probate Court...The Temporary Commitment of (first and last name of PI #1):

Review of the "Temporary Commitment Order dated 10/19/14 revealed
PI # 1 posed a real and present threat of danger to self or to others, and that the threat of danger has been evidenced in that, "Danger to self/others. Please hold for further evaluation. Ordered that Sheriff / Ambulance take the said Respondent into custody and arrange transportation to (name of Psychiatric Hospital). Authorized and Ordered by (Probate Judge's name)."


2). Hospital Policy and Procedure:

Title: Restraint and Seclusion #: DK-TX-136.00

Effective: 1/1/97 Approval: 2/27/14

Definitions:

Restraint: Any physical or mechanical device, material, medication or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely.

Instances Where Restraint and Seclusion Standards Do Not Apply:

...G...Correction restrictions for security purposes. The use of handcuffs...applied by law enforcement officials is for custody, detention and public safely reasons, and is not involved in the provision of health care. Therefore, the use of restrictive devices applied and monitored by law enforcement is not a restraint.


Type of Restraint:

A restraint is either a Non-violent, Non-Self destructive or Violent / Self Destructive Behavior restraint.

Violent / Self Destructive Behavioral Reasons for the use of restraint:

...To manage violent or self destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member or others

Policy:

A. It is the policy of the facility to:

...c. Limiting the use of restraints...to emergencies where there is a risk to the patient harming self or others...

E. Orders for Restraint

i. The physician...responsible for the care of the patient is authorized to order a restraint...Orders should:

a. Be for each use of the restraints and related to a specific episode of the patient's behavior...

ii. In an emergency application situation, a RN who has documented Restraint...competency may initiate the application of restraint...prior to obtaining an order from an Licensed Independent Practitioner...the order must be obtained during the emergency application or immediately (within a few minutes) after the restraint..has been applied...

L. Documentation:

Each episode of restraint is documented in the patient's medical record...

i. Circumstances and patient's...symptoms that led to restraint use, description of patient's behavior...

iii. Rationale for the type of interventions selected...
v. Written orders for use...

3). Interviews:

During an interview on 10/31/14 at 8:45 AM, PI # 1's Attending Physician / Employee Identifier (EI) # 3, stated hospital staff notified her via telephone that PI # 1 was very agitated, hit staff, and the police had been called. According to the physician, PI # 1 was severely depressed and violently agitated. The hand cuffs, "Was the fastest way to calm PI # 1." The surveyor asked the reason restraints were not considered and the physician replied restraint is, "Not always best. The patient may not be able to protect their airway (example: possible vomiting)."

During an interview on 10/31/14 at 3:20 PM, the ICU Director, Employee Identifier / EI # 1, stated PI # 1 was in ICU Room X. A Corrections Officer was guarding another patient (in custody of law enforcement) also in ICU. PI # 1 had a court order for a hold. According to the Director, the use of restraints was discussed with PI # 1's Attending Physician. However, no physician order for restraint or related documentation regarding this discussion was found in PI # 1's medical record.


During an interview on 10/31/14 at 3:20 PM, the ICU Director, Employee Identifier / EI # 1, was asked how staff would have managed PI # 1's behavior if the corrections officer had not been present. The Director replied, "We would have put soft restraints on...at 7:00 PM."