HospitalInspections.org

Based on medical record review, policy review and staff interview it was determined the facility failed to ensure the type or technique of restraint used was the least restrictive intervention to protect the patient from harm for one (#5) of ten patients sampled.

Findings included:

Review of the medical record for patient #5 revealed the patient presented to the facility Emergency Department (ED) on 12/4/2020 for complaints of chest pain. Upon evaluation the physician determined the patient had major depression with suicidal and homicidal ideation and was admitted. Review of the record revealed the psychiatrist was consulted and evaluated the patient on 12/4/2020 at 12:30 pm. Review of the record revealed the patient was admitted under the Baker Act for further treatment and placed in a Careview room (Careview monitors patients 24/7 via camera).

Review of the nursing note, dated 12/6/2020 at 10:05 am, revealed at approximately 8:50 am the patient was observed heading toward the elevators and was able to make his way down to the lobby before being apprehended by police and security. The patient was returned to his room, was apologetic and stated, "I was just bored, I wanted to see what I could get away with." The nurse documented the patient was placed in two point soft wrist restraints and was informed of the reasoning and criteria for restraints to be removed. The nurse documented at approximately 9:00 am the patient removed the restraints and was found in the bathroom. The patient was returned to bed and the restraints reapplied. The nurse documented the patient was at risk for self harm and was under the Baker Act.

Review of the nursing note, dated 12/6/2020 at 6:50 pm, revealed the patient continued to remove and replace the restraints at will. The nurse documented the patient did not appear to be harmful to self but the nurse feared he may become violent if given the opportunity. Review of the record revealed the restraints remained on until 12/7/2020 at 6:00 am.

Review of the facility policy, "Suicide Screening and Precautions," stated the RN (Registered Nurse) will determine the appropriate interventions and implement immediately upon identification based on assessed risk. The policy stated for patients at high risk interventions would include 1:1 patient safety attendant and staff member would accompany the patient to the bathroom and maintain line-of-sight at all times. The policy further stated after reassessing a patient and determining that the patient is at a decreased risk for suicide the RN will collaborate with the physician regarding patient condition and will adjust the interventions based on risk level.

An interview was conducted with the Interim Vice President of Quality on 12/09/2020 at 10:25 am at which time the above findings were reviewed and confirmed.