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Based on review of documents, patient charts, and interview, the facility failed to ensure physician orders were received to initiate seclusion in two out of two secluded patients. Patients (2 of 2) in the Emergency Department were placed in seclusion without physician's order and/or assessments.


Refer to TAG A0168 for further information.

Based on review of documents, patient charts, and interview, the facility failed to ensure physician orders were received to initiate seclusion in two out of two secluded patients (Patient #22 and Patient #24).


A review of charts for two secluded patients (Patient #22 and Patient #24) revealed the following:


1. Patient #22 was a 45 year old male, who was brought to the emergency department on June 21, 2016, at 8:21 am by the police. The nursing notes documented at 8:30 am. that the patient is on a one to one observation. He was uncooperative and appeared to be hallucinating with flight of ideas. On June 21, 2016, at 9:12 am, Emergency Detention Warrant paperwork was signed.


At 5:53 PM, the nursing notes recorded, "PT RESTING AT THIS TIME ...ALL DOCUMENTATION FOR SECLUSION ON THE CLOSE OBSERVATION CHECK SHEET"


At 7:20 PM, the nursing notes recorded, "PT RESTING IN BED. PT REMOVED FROM SECLUSION AT THIS TIME."


A review of physician orders in the chart for patient #22 did not include any orders to initiate or end seclusion of the patient.


Interview with Staff #7 confirmed that no order for seclusion could be found in the medical record.


Staff #2 confirmed via email on July 22, 2016, that no physician order for restraints was found.


2. Patient #24 was a 50 year old female, brought to the emergency department by Emergency Medical Services with police on June 22, 2016, at 10:05 am. The patient was experiencing auditory and visual hallucinations and had cuts to her feet from walking outside without shoes. Court commitment paperwork was initiated that morning.


At 11:58 am, nursing notes stated seclusion was initiated because the patient was a danger to self or others and a risk of injury to self.


A review of physician orders in the chart for patient #24 did not include any orders to initiate seclusion of the patient.


A review of Policy number 3.080, Christus Health Clinical Policy: Standardized Use of Restraint and/or Seclusion revealed the policy did not clearly identify the processes for initiating, documenting, and monitoring seclusion or instruct that the processes that wer outlined in the policy for restraints were expected to also be followed for seclusion.


On page 3 of 11, definition E, Seclusion stated a seclusion is, "The involuntary confinement of a patient alone in a room or area from which the patient is physically prevented from leaving. Seclusion is used only for the management of violent or self-destructive behavior."


On page 3 of 11, under the heading "IV. Process: A. Patient Assessment", verbiage discussed restraints with one reference to seclusion. That was, "Restraint usage or seclusion is not based on patient restraint history or solely on history of dangerous behavior.


Item B on page 4 of 11 did not mention seclusion.


Item C stated, "Restraint and/or seclusion are used only when less restrictive, alternative interventions are ineffective. See list of alternatives below:" The two categories of alternatives were, "Alternatives to Restraints: Non violent or non self-destructive" and "Alternatives to Restraint: Violent or destructive behavior". There was not a category for alternatives to seclusion. It was not stated that seclusion is to be treated the same as a restraint.


Item D on page 4 of 11 did not mention seclusion.


Item E on page 4 of 11 stated, "The use of restraints and/or seclusion necessitates a written modification of the patient's plan of care."


Page 5 of 11 contained two boxes with procedures for initiating restraints. The first column was titled, "Restraint Orders: Non violent or non self-destructive". Seclusion was not mentioned in this column. The second column was titled, "Restraint Orders: Violent or self-destructive behavior". Items 1 and 2 in the second column referred to obtaining an order for restraints and the time limit of the order. Seclusion was not mentioned. It was not stated that seclusion was to be treated the same as a restraint. Item 3 referred to the Face-to-Face evaluation and documentation for restraints and seclusions. Item 4 and Item 5 (continued on page 6 of 11) did not mention seclusion.


Items F, G, and H on page 6 of 11 did not mention seclusion.

Based on observation, interview, and record review, the facility failed to ensure medical supplies and equipment were maintained in a manner to ensure patient safety in 1 of 1 unit (Sexual assault nurse's examiner room in the Emergency Department).


This deficient practice had the likelihood to cause harm to all patients presenting to the room.


Findings:


During an observation on 07/19/2016, after 9:00 a.m., the following was found in the Sexual assault nurse's examiner room in the Emergency Department:


Four boxes of sterile water which held up to 1000 vials was found stored in a cabinet and in use. They had an expiration date of August 2015.


Staff #13 confirmed the observation and reported the sterile water was used for obtaining specimens.


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17 out of 17 BD Twinpack (brand name) Syringe Filling and Needleless Delivery System packages were found in a cabinet and in use with an expiration date of August 2015.


4 out of 6 BD Vacutainer blood collection tubes were found in a cabinet and in use with an expiration date of December 2015.


A single use vial of Lidocaine HCL 1% was found opened and in a cabinet for use. The vial appeared to have a date written on the label consistent with an opening date, but was illegible. Staff #13 confirmed it was a single use vial and should not have been in the cabinet, unsecured, and opened.


The refrigerator log for storing food for patients was found on the door of the refrigerator. The log was dated at the top for June 2016. June 6 and June 7 temperature blocks had initials in temperature blocks below the specified range without any corrective action taken. The only temperature check recorded after June 9th was on June 15, June 20, and June 27. Because of the poor copy quality of the original form, it was difficult to see the original initials. Staff # 13 confirmed the findings.