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Based on interview and record review, for one (Patient 20) of 31 sampled patients, the hospital nursing staff failed to follow the physician's order to renew restraints or clarify the need for restraints on four consecutive days during the patient's hospitalization. This failure resulted in the continued use of four point (all limbs) restraints for 96 hours without renewal orders from the prescribing physician.

Definitions:

Intellectual disability: A learning disorder (Tabor's Cyclopedic Medical Dictionary, 21st Edition).

Intermittent explosive disorder: A personality disorder marked by episodes of impulsive aggressiveness disproportionate to precipitating events; in contrast to a one-time outburst, this is a pattern of behavior (Tabor's Cyclopedic Medical Dictionary, 21st Edition).

Nonverbal autism spectrum disorder: Autism is a disorder characterized by withdrawal from communication with others, often accompanied by repetitive or primitive behaviors; spectrum disorder is a synonym for the group of illnesses known as "classical" autism, Asperger's (Tabor's Cyclopedic Medical Dictionary, 21st Edition).

Rectal prolapse: Occurs when part of the large intestine's lowest section (rectum) slips outside the muscular opening at the end of the digestive tract (anus) and can cause fecal incontinence [Reference: Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/rectal-prolapse/symptoms-causes/syc-20352837]

FINDINGS:

Record review on 3/7/19 of the psychiatrist's (specializes in mental, emotional, or behavioral disorders) progress notes dated 10/15/18 indicated Patient 20 was a 15-year old admitted to the hospital on 7/2/18. Patient 20 exhibited repetitive self-mutilating behaviors and diagnosed by the child and adolescent psychiatrist (MD 1) with severe nonverbal autism spectrum disorder, intellectual disability, intermittent explosive disorder, and was treated for rectal prolapse. Patient 20 was placed in four-point restraints for safety and self harm behavior.

On 10/14/18, the physician (MD 3) renewed the existing restraint order for another 24 hours (10/15/18) and noted, "[Patient 20] has the diagnosis of severe Autism, an irreversible, permanent 'chronic medical and psychiatric condition.' [Patient 20] has clearly and consistently demonstrated a constant risk of engaging in both self-mutilating harm and harm to others, even with aggressive escalation of his psychiatric medical regimen. In addition his restraints are required due to his actions interfering with his medical care. With his specific diagnosis, and this baseline clinical state, he is not a candidate for removal of restraints and qualifies for need for continuous standing restraints at this time." MD 3 wrote, "Patient meets exception criteria for order renewal q [every] 24 hours and NOT q2 hours."

Further medical record review indicated the restraint orders were not renewed on 10/16/18, 10/17/18, 10/18/18, and 10/19/18.

Record review of the policy and procedure (P&P) titled, "Restraints" and approved 01/'18 indicated as follows: 5.18.8.3 "If a patient is diagnosed with a chronic medical or psychiatric condition . . . and the patient engages in repetitive self-mutilating behavior, a standing or PRN [as needed] order for restraint to be applied in accordance with specific parameters established in the treatment plan would be permitted. Since the use of restraints to prevent self-injury is needed for these types of rare, severe, medical and psychiatric conditions, the specific requirements (1-hour face-to-face evaluation, time-limited orders, and evaluation every 24 hours before renewal of the order) for the management of violent or self-destructive behavior do not apply." In Appendix D, the "Restraint Application for Violent, Self-Destructive Behavior Management," indicated the orders "may be written for up to a total of 24 hours."

During an interview on 3/7/19 at 9:12 a.m., with members of Patient 20's care team that included, but was not limited to, the internal medicine doctor (MD 2), the director of nursing and clinical practice (DON), and chief of pediatric medicine (CPM), each concurred that Patient 20 met the "exception criteria" of the hospital's Restraints P&P due to Patient 20's chronic psychiatric condition. Furthermore, the restraints were used as a safety measure, and not for behavioral control. Per the hospital's policy, the restraint order did not have to be renewed every 2 hours, as would generally be done for a 15-year old without a chronic psychiatric condition. MD 2 stated the restraint order was not a standing order.

According to the care team, the four registered nurses (RN's) responsible for acknowledging and renewing the physician orders for restraint use were non-hospital employees. The hired contracted RNs were experienced in working with severely autistic patients to provide around-the-clock, one-on-one nursing care exclusively for Patient 20 during the entire hospital stay. (Note: The four contracted RNs were not available for interviews during the survey).

Record review of MD 1's progress note dated 10/15/18 indicated, "This patient has severe autism, and his chronic medical/psychiatric condition in conjunction with his repetitive self-mutilating behavior qualifies him for restraint order review and renewal every 24 hours. In addition his restraints are required due to his actions interfering with his medical care. This situation has been reviewed today and it remains unchanged."

Further review of the physician's progress notes dated 10/16/18, 10/17/18, 10/18/18, and 10/19/18, indicated Patient 20 was seen by resident physician in training (MD 4) and attending physician (MD 5). However, the restraint order was not renewed and the need for restraints was not addressed by MD 4 or MD 5 in their progress notes. In addition, there was no documentation that nursing staff contacted the physician to renew the restraint order on 10/16/18 through 10/19/18.

Record review of the nurse's flowsheets for "Restraints, Behavioral/Violent" showed during 10/16/18 through 10/19/18, Patient 20 remained in four-point restraints, and the RNs assigned to Patient 20 continued to chart their monitoring of restraints every 15 minutes.