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Based on interview, review of the patient record, and grievance file, it is revealed that a complainant representing patient #1, (one of 10 closed and 5 open records reviewed) did not receive a resolution letter regarding the grievance.


Patient #1 is a Medicare recipient who was admitted on 11/25/2012, and discharged on 11/28/2012. Patient #1's Power of Attorney contested patient #1's discharge when patient #1 did not meet the three-day stay for continued benefits. However, patient #1 had no acute process to justify a continued stay in the hospital.


The complainant was informed of the Medicare Important Message, but did not appeal the discharge. Per hospital documentation and interview, it is evident that a great deal of time was spent investigating the complainant's grievance and informing the complainant of options to appeal, or to have a referral to a stepped-down level of care. The complainant instead took patient #1 home with her.


Interview with hospital administration on 2/27/2013 reveals that no formal resolution letter was sent to the complainant and therefore, the hospital did not meet regulatory directives of giving a written notice of the investigation results.

Based on a review of hospital policy and review of 10 closed records and 5 open records, it is determined that the hospital did not inform patient #7 regarding advance directives upon his request.

Patient #7 is a Medicare recipient who was admitted on 11/25/2012. On admission, staff inquired if patient #7 had an advance directive, to which he replied "No." Staff further inquired if patient #7 would like more information regarding advance directives, to which he responded "Yes." There was no other documentation that any staff member provided the requested information to patient #7.


The hospital's policy for Advance Directives states "If the patient does not have an Advance Directive:
? Provide the patient with verbal and written information about advance directives so that he can make an informed decision about developing one.
? Answer the patient's questions about an advance directive or have a social worker or patient representative discuss advance directives with him to provide accurate information."

Based on the records reviewed, the hospital failed to give patient #7 more information regarding Advance Directives, as was his right to receive.

Based on review of hospital's Quiet Room Policy (revised July 7, 2012), it was determined that the involuntary use of the room would be considered to be seclusion:

The hospital policy, "Quiet Room Use" reveals in part, "The major difference between the use of the quiet room and the use of a seclusion room is that the doors of the quiet room may remain open." and "Ensure that there are adequate help for placing your patient in the quiet room, especially if he hasn't requested this placement."


Based on the policy directives, Quiet Room as described, is not considered a voluntary process, and patients may be forced to utilize the quiet room. Therefore, the policy as written is considered seclusion. While there was no use of the quiet room during the survey to determine how it is used in practice, the certain aspects of the quiet room policy are tantamount to seclusion.

Based on a review of restraint order entry and hospital quality monitoring, it is revealed that 1) Physician orders prior to February 16, 2013 did not specify the number of restraint points (2 point or 4 point) therefore leaving the determination to nursing staff, and 2) No justification of restraint is found for two of 5 closed restraint records reviewed for patient #4 and #5.

Review of restraint orders in medical records prior to February 16, 2013 reveal detail for the type of restraint (Soft limb, or Locked Rubber), but the orders fail to specify the number of points to be used, e.g., two-point wrist, or 4-point bed restraint. Therefore, the decision of how many points to use was left to nursing discretion. The hospital failed to specify the number of restraint points for patients requiring restraint prior to February 16, 2013.

Patient #4 is a 32-year-old who presented via police to the emergency department for alcohol intoxication in November of 2012. Patient #4 was initially restrained in 4-point restraint at 2245. Per the 15-minute flow documentation, patient #4 had become combative. On entry to the ED, nursing asked patient #4 to remain calm following the removal of police cuffs, which occurred at 2251. Following the removal of cuffs, the nurse documented "Remains hyper-verbal and tearful." There is no documentation of actual combative behavior by the nurse. Therefore, there was no justification for the use of restraints after the removal of those cuffs.

Patient #5 who is developmentally disabled presented to the emergency department (ED) in November 2012 with suicidal ideation. Patient #5 was placed in 4-point restraints when becoming violent with staff, and was removed from restraint after calming down. Patient #5 then attempted to run out of the ED. When patient #5 was brought back to the ED treatment room, patient #5 crawled under the treatment table on her back, and began to slap hands and feet on the floor. Staff subsequently placed patient #5 in 4-point restraint though patient #5's behavior did not represent imminent danger to self or others, and the least restrictive intervention such as continued supervision could have been utilized.

The hospital failed to utilize least restrictive interventions to protect patients and others from harm.

Based on review of 5 closed restraint records, and interview of the behavioral health unit staff, It was determined that 1) The record for closed inpatient #2 reveals no modification of his care plan and 2) Though required by policy and regulation, staff do not make modifications to plans of care for patients in seclusion and restraint.


Patient #2 is a 32-year-old who in December 2012, was emergency petitioned to the emergency department, and later certified by two physicians to require in-patient treatment for suicidal ideation with plan. Patient #2 was admitted to the unit and during a meal, became violent with staff.


Patient #2 was restrained in 4-point restraints for approximately 1.5 hours. However, no modification to the treatment plan is found in the record.


Restraint & Seclusion Policy (effective 8/2012) reveals "Nursing Documentation Requirements in part, as "(7) Revisions to the plan of care." Interview with staff on 2./27/2013 failed to reveal how staff may have modified a plan of care for the patients who are restrained or secluded.


There was no documentation that the hospital staff modified the plan of care for patients requiring restraint and seclusion.

Based on a review of 5 closed restraint records, patients #4, 5, and 14 were not released at the earliest possible time.


Patient #4 is a 32-year-old who presented via police to the emergency department in November of 2012 with alcohol intoxication. Patient #4 was initially restrained in 4-point restraint at 2245 due to combative behaviors. At 0030 restraints were decreased to two-point, (an arm and a leg) until release at approximately 0145.


While patient was noted as crying, irritable and agitated, no combative behaviors had been noted since 2300. At 0030, a nurse writes that "Rt arm and Rt leg removed D/T (due to) PT (patient) calming down and no longer cursing at this nurse after lengthy discussion about appropriate ED language and treatment with staff."


While calm behavior is desirable for release of restraint, criteria for release is not dependent on patients refraining from cursing, or being absolutely calm. Criteria for patient #4 to be released from restraint was met when documentation of combative behaviors ended at 2300.


Patient #5 who is developmentally disabled presented to the emergency department (ED) in November 2012 with suicidal ideation. Patient #5 was placed in 4-point restraints when becoming violent with staff, and was removed from restraint after calming down. Patient #5 then attempted to run out of the ED. When patient #5 was brought back to the ED treatment room, patient #5 got under the treatment table on her back, and began to slap hands and feet on the floor. Staff subsequently placed patient #5 in 4-point restraint though patient #5's behavior did not represent imminent danger to self or others.

Patient #14 is a 20-year-old developmentally disabled male who presented to the hospital in February 2013. Patient #14 was placed in 4-point restraints at 2230 when he became combative and attempting to bite.

Fifteen-minute flows reveal that patient #14 remained combative through 2330, then was documented as quiet through 0030 of the following morning, and then asleep until he was released at 0215. Therefore, patient #14 was restrained for almost three hours with no behavior that justified restraint use.

Based on a review of hospital Restraint & Seclusion Policy, interview with Administrative Staff, and review of closed records for patients #2, 4, and 5, there was partial or no evidence of the required face to face evaluation.


The hospital "Restraint & Seclusion Policy (effective 8/2012)" states "Ordering LIP Responsibilities" as an " ...Initial Face-to-Face Evaluation." However, the required elements of the face-to-face are listed under nursing responsibilities, and nursing does not receive the training required for performing a face-to-face evaluation.

Interview with Hospital Administrative Staff reveals that until February 19, 2013, the electronic order entry had no face-to-face element attached to orders for restraint and seclusion. Currently order entries do provide documentation that a face-to-face was done or not done, indicated by a "Y" (yes), or "N" (no). The summary "Yes" or "No" does not serve as the thorough evaluation required by the face to face.


Patient #2 is a 32-year-old who in December 2012 was emergency petitioned to the emergency department, and was later certified by two physicians to require in-patient treatment for suicidal ideation with plan. Patient #2 was admitted to the unit and during a meal, became violent with staff.


Patient #2 was restrained in 4-point restraints for approximately 1.5 hours. Physicians saw patient #2 at 1218 and 1310. Patient #2 sustained a raised welt to the right eye, but neither physician addressed patient #2's physical status with regards to the injury. Additionally, neither physician addressed patient #1's response to the restraint intervention.


Patient #4 is a 32-year-old who presented via police to the emergency department for alcohol intoxication in November of 2012. Patient #4 was initially restrained in 4-point restraint at 2245 due to combative behaviors. At 0030 restraints were decreased to two-point, (an arm and a leg) until release at approximately 0145. A physician exam of 2354 which could serve as a face-to-face, identified that patient #4 "Cries with tears" but did not identify any combative behaviors. Additionally, the physician stated that patient #4 was neither suicidal nor homicidal. However, the physician did not address whether patient #4 could come out of restraint.


Patient #5 who is developmentally disabled presented to the emergency department (ED) in November 2012 with suicidal ideation. Patient #5 was placed in 4-point restraints when becoming violent with staff, and was removed from restraint after calming down. Patient #5 then attempted to run out of the ED. When patient #5 was brought back to the ED treatment room, patient #5 got under the treatment table on her back, and began to slap hands and feet on the floor. Staff subsequently placed patient #5 in 4-point restraint though patient #5's behavior did not represent imminent danger to self or others.

The physician re-evaluations at 2115 reveals "Pt was jumping off bed and was unable to be controlled. Had to restrain pt," and at 2344, "Pt tried to run out of ED, and then threw (self) on the floor. Had to be restrained again." The physician re-evaluations do not meet all elements of a face-to-face.
The hospital fails to meet regulatory directives for performing a face-to-face

Review of 5 closed restraint records reveals that in one (patient #4) of the 5 records reviewed there was no documentation of the application of the least restrictive interventions.


Patient #4 is a 32-year-old who presented via police to the emergency department for alcohol intoxication in November of 2012. Patient #4 was initially restrained in 4-point restraint at 2245. Per the 15-minute flow documentation, patient #4 had become combative. However, on entry, and following the removal of hand cuffs by police at 2251, no contemporaneous nursing documentation reveals how or when patient #4 became combative.


Additionally, a physician assessment of 2354 reveals "Pt tearful in room. Was apparently combative with police. In restraints upon examination." Patient #1 had been released from police handcuffs just three minutes earlier, and no further nursing documentation reveals the justification for ED restraint, or the least restrictive interventions utilized prior to initiating that restraint.

Review of 5 closed restraint records reveals that patient #4 was restrained in two point unilateral restraint which presented a safety issue when patient #4 attempted to climb out of the bed.


Patient #4 is a 32-year-old who presented via police to the emergency department for alcohol intoxication in November of 2012. Patient #4 was initially restrained in 4-point restraint at 2245. Per the 15-minute flow documentation, patient #4 had become combative.


At 0102, a nursing note reveals, " Per sitter, pt tried to climb over the railing since her rt (right) arm and rt leg were both restrained. Pt ' s LT (left) leg was released and RT leg was restrained to prevent this from happening again. "


Unilateral restraints do not meet the standard for safe restraint technique as demonstrated by patient #4 where patients may attempt to leave the bed and cause injury.

Based on a review of 10 closed records, it is determined that patient #6 had no discharge summary, and patient #8 had a discharge summary which was late.

Review of patient #6 ' s record who was admitted from 11/27 through 12/3/2012 revealed no discharge summary.

Review of patient #8 ' s record who was admitted from 11/29 through 12/2/2012, reveals a discharge summary which was not completed until 1/30/2013.

The hospital failed to promptly complete records for patients #6 and #8.