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Based on policy and procedure review, medical record review, and staff interviews, hospital staff failed to order a violent restraint per hospital policy for a patient placed in 4-point restraints in 1 of 4 restraint records reviewed (Patient #4).

The findings include:

Review of the policy and procedure titled "Restraint Seclusion" revised 11-2021 revealed " ...Definitions ...Violent/Self Destructive Restraint: A restraint applied when the patient demonstrates violent or self-destructive behavior; that which jeopardizes the immediate physical safety of the patient, visitors, or staff members. Includes actions, but not limited to hitting, kicking, mutilating or other physically aggressive behaviors. A restraint that fully immobilizes a patient is considered a violent restraint (i.e., 4-point restraints)."

Open medical record review on 12/15/2021 revealed Patient #4 was a 70-year-old male admitted to the MNU (medical neurology unit) unit on 11/30/2021 for alcohol detox. Review revealed a Psychiatric consult was placed on 12/01/2021 for "Rapidly worsening agitation and confusion ...Alcohol withdrawal with confusion." Review revealed Patient #4 was placed in bilateral soft wrist restraints and a vest (medical restraint used to restrain a patient to a bed or chair) on 12/01/2021 at 1900 due to "interference with medical treatment." Review of a "Significant Event" note dated 12/01/2021 at 2023 revealed "I was informed by MNU staff that 1 of the nurses got 'slammed against the wall' by the Patient (#4) ...Patient appeared to be agitated and confused ...Patient remains agitated despite being given IV (intravenous) lorazepam (sedation medication) and on tapering dose of phenobarbital (medication used to treat alcohol withdrawals) ...Since he displayed unsafe behavior, patient temporarily placed on (sic) vest restraints and wrist restraints ..." Review revealed Patient #4 was placed in bilateral soft wrist and ankle restraints on 12/01/2021 at 2300 for "Potential for self-harm; Removal of dressing; Removal of equipment; Pulling lines/tubes." Review of a progress note by PA #1 (Psychiatric Physician Assistant) dated 12/02/2021 at 1009 revealed " ...Upon entry to room patient is lying in bed in 4-point restraints and Posey vest ..." Review of a progress note by PA #1 dated 12/03/2021 at 1025 revealed " ...Patient is still in 4-point restraints due to his behavior ..." Review revealed an order was placed on 12/03/2021 at 0222 for "Restraints non-violent or non-self destructive" for jacket/vest and bilateral soft wrist and ankle restraints due to "interference with medical treatment." Further review of the medical record revealed Patient #4 remained violent, agitated, and aggressive, confused, delirious, interfered with medical care, uncooperative, and pulled out multiple IVs and NG (nasogastric) tube throughout the timeframe he was in 4-point restraints. Review revealed subsequent restraint orders for 12/03/2021 through 12/10/2021 were "Restraints non-violent or non-self destructive" for jacket/vest and bilateral soft wrist and ankle restraints due to "interference with medical treatment." Review revealed on 12/10/2021 at 1300 Patient #4's 4-point restraints were discontinued.

Interview on 12/15/2021 at 1130 with PA #1 (Psychiatric PA) revealed she cared for Patient #4 following his admission. PA #1 stated Patient #4 was "acutely altered" and easily agitated. PA #1 stated Patient #4 would attempt to hit staff with his arms and kick them with his legs. PA #1 explained Patient #4 kept sliding and thrashing around in the bed. Interview revealed Patient #4's behaviors warranted 4-point restraints and vest to protect himself and staff from harm. PA #1 stated "I'm not sure, I have no idea" if a 4-point restraint was classified as a violent or non-violent restraint. Interview revealed PA #1 was not aware the restraint policy defined fully immobilizing a patient (i.e., 4-point restraints) as a violent restraint.

Interview on 12/15/2021 at 1315 with RN #5 revealed she cared for Patient #4 on 12/01/2021 night shift (when he went into restraints). RN #5 stated over the shift Patient #4 became less directable, increasingly uncooperative, kicking and pulling at his lines and IVs. RN #5 stated Patient #4's behavior warranted 4-point restraints to maintain his safety. Interview revealed most all restraints were ordered as non-violent restraints, even if the order was for 4-point restraints.

Interview on 12/15/2021 at 1333 with MD #6 (Psychiatric MD) revealed during her care for Patient #4 he was delirious and aggressive. Interview revealed the psychiatric providers did not place restraint orders, that was the responsibility of the patient's attending medical doctors.

Interview on 12/15/2021 at 1354 with RN #7 revealed during her care for Patient #4 he was "lethargic, confused, kicking and trying to crawl out of the bed." Interview revealed Patient #4 pulled his NG tube out during her shift. RN #7 explained Patient #4 was receiving medications for agitation however they were not controlling his behaviors. RN #7 explained she generally got orders for restraints from the medical provider via telephone or verbal order and then placed the order in the system. RN #7 stated when she placed the order in the system, she entered the order under non-violent restraints even for 4-point restraints. Interview revealed RN #7 was unaware 4-point restraints were considered violent restraints per hospital policy.

Interview on 12/15/2021 at 1407 with the Director of Nursing Excellence revealed when ordering restraints, the default order was for non-violent restraints and then staff would select bilateral wrist and ankle restraints if applicable. Interview revealed when non-violent or violent restraints were ordered, that automatically pulled in the ordered restraint flowsheet for nursing staff to document. Interview revealed following the hospitals accrediting organization survey in October 2021, updated restraint education was distributed to the nursing staff related to chemical restraints and restraint policy updates. Interview revealed the restraint education was developing and ongoing for the nursing staff. Interview confirmed per policy, Patient #4's restraints should have been ordered as violent restraints.

Interview on 12/16/2021 at 1224 with RN #9 revealed he participated in Patient #4's care. RN #9 stated Patient #4's behaviors were initially violent and aggressive towards staff and an order was obtained to apply wrist restraints to Patient #4. RN #9 stated Patient #4 was "very delirious" and was at risk for harm to himself. RN #9 stated Patient #4 required restraints primarily for non-violent behaviors such as pulling at his electrodes (medical equipment used to monitor a patient's heart), attempting to "eat his electrodes," pulled out multiple IVs, pulled out his nasogastric tube, pulling at his foley catheter (system used to collect urine), and sliding and twisting in the bed. RN #9 stated the nurses primarily drive the restraint orders, the nurses report to the physicians the patient's behaviors and obtain an order to start restraints. RN #9 stated the physicians were good about asking the nurses had they tried the patients ordered medications or what least restrictive interventions had been done before giving an order for restraints. Interview confirmed RN #9 was unaware that 4-point restraints were considered violent restraints per hospital policy.

Based on policy and procedure review, medical record review and staff interviews, the hospital staff failed to obtain a physician order for restraints for 1 of 4 restrained patient records reviewed (Patient #9).

The findings include:

Review on 12/15/2021 of the hospital policy and procedure titled "Restraint Seclusion", revised date 11/2021, revealed "... If restraint/seclusion are discontinued prior to the expiration of the original order, a new order must be obtained prior to re-initiating restraint/seclusion. ..."

Open medical record review on 12/15/2021 for Patient #9 revealed a 58-year-old male admitted to the hospital on 12/13/2021 at 0932 with a diagnosis of dyspnea. Review of the medical record revealed a verbal order for non-violent restraints was placed on 12/13/2021 at 1809. Review of the nursing restraint monitoring documentation revealed Patient #9's restraints were discontinued on 12/14/2021 at 0300. Further review of the nursing restraint monitoring documentation revealed Patient #9's restraints were re-applied on 12/14/2021 at 0800. Continued review of the nursing restraint monitoring documentation revealed Patient #9's restraints were discontinued on 12/14/2021 at 1300. Nursing documentation revealed Patient #9's restraints were re-applied on 12/14/2021 at 1600 and discontinued at 2002. Review of the medical record revealed no available documentation of a physician order for the reapplication of restraints on 12/14/2021 at 0800 and 1600.

Interview on 12/15/2021 at 1130 with the Quality Director during review of the medical record revealed that if restraints were discontinued prior to the expiration of the original order, the staff were expected to obtain a new order when restraints were re-applied. Interview revealed there was no available documentation of a new restraint order with the reapplication of restraints for Patient #9 on 12/14/2021 at 0800 and at 1600.

Based on review of hospital policy and procedure, physician credential files and staff interviews the hospital failed to ensure a physician completed restraint and seclusion training for 1 of 1 physician files reviewed (#1).

The findings include:

Review on 12/15/2021 of the hospital policy and procedure titled "Restraint Seclusion", revised 11/2021, revealed "... I. Skill Level and Education Training requirements for qualified staff with direct or indirect patient responsibilities: Job Title ... Advanced Practice Providers ... Required Education/Certification ... Orientation and Annually: * Successful completion of Restraint CBL (Computer Based Learning) for Providers. ..."

Review on 12/15/2021 around 1500 of three (3) Provider Credential files revealed no documentation that PA #1, MD #2 and MD #3 had received training in restraints/seclusion.

Interview on 12/15/2021 around 1500, during review of the credential files, with the Director of Medical Staff Services revealed there was no available documentation of restraint/seclusion training for the Providers. Interview revealed a copy of the Computer Based Learning transcripts was not available in the Provider credential files.

Interview on 12/15/2021 around 1730 with the Vice President (VP) of Quality revealed restraint/seclusion education material was sent via electronic mail (date unknown) to the Medical Staff Services Department. Interview revealed the VP was unable to locate a copy of the electronic mail that included the restraint/seclusion education materials prior to survey exit.

Based on review of hospital policy and procedure, internal hospital memos, grievance log review, medical record review and interviews with staff and physicians, the hospital staff failed to allow the legal guardian of a minor visitation rights for 1 of 2 minor patient records reviewed (Patient #6).

The findings include:

Review on 12/15/2021 of the hospital policy and procedure titled "Informed Consent", reviewed date 11-2020, revealed "... Legal Age of Consent to Treatment: ...5. Any minor may give effective consent...for medical health services for the prevention, diagnosis, and treatment of: ...*Pregnancy ..."

Review on 12/14/2021 of an internal hospital memo dated 08/09/2021 revealed the number of visitors allowed with patients receiving care in the Emergency Department was changed from one (1) visitor to no visitors. Further review of the memo dated 08/09/2021 revealed pediatric patients will be allowed one healthy adult support person. Review of an internal hospital memo dated 10/19/2021, effective 10/20/2021, revealed the number of visitors allowed with patients receiving care in the Emergency Department was changed from no visitors to allowing 1-2 visitors.

Review on 12/14/2021 of the Hospital Grievance Log revealed a grievance filed by Patient #6's legal guardian on 09/24/2021 regarding visitor restrictions. Review of the grievance revealed "Ms. (Name) states Patient #6 whom she is the guardian of came in to (Name)-ED on Tuesday night (09/21/2021). She states Patient #6 is pregnant and came in with concerns over her pregnancy. She states when Patient #6 was brought back; she was not allowed to go back to the room with her due to visitor restrictions. She states Patient #6 didn't want a male doctor due to a history of sexual abuse as a child. She states Patient #6 needed a support person, and she was not allowed to be there for her. She states the doctor had no compassion for Patient #6 and her history. She states the doctor would not hear her concerns as she was not allowed back with Patient #6. She states she attempted to bring this to the staff's attention but feels she was talked down to. She states Patient #6 was very tearful after leaving the hospital and feels this 'may cause a setback in her mental state'. She states she feels this needs to be addressed.... I stated unfortunately due to the contagious nature of Covid our restriction were in place to prevent the spread. I asked Ms. (Name) if Patient #6 shared her concerns, she stated yes. ... I was unclear of Ms. (Name) expectations for our conversation and asked if she was just making me aware of the concerns or if she was requesting feedback. She states se (sic) would like feedback. I stated in order for her to get feedback, I would need to speak with Patient #6 to get permission to share feedback with her. Otherwise, the review would be internal. She states she will attempt to ask Patient #6. I could hear her talking to Patient #6 in the background and shortly after she handed the phone to Patient #6. I introduced myself and stated Ms. (Name) had informed me of some concerns she had during her ED visit. I stated Ms. (Name) was requesting feedback on these concerns and asked if she gave me permission to share the findings of my review. Patient #6 states 'yes'. ..."

Closed medical record review on 12/14/2021 for Patient #6 revealed a 17-year-old female that presented to the Emergency Department (ED) on 09/21/2021 at 2138 with arrival complaint of "6 months preg (pregnant), no baby movement and spotting." Review of the Consent for Treatment revealed the Legal Guardian signed the consent form on 09/21/2021 at 2139. Review of the Triage Nursing Note dated 09/21/2021 at 2152 revealed chief complaint "Pregnancy Problem (patient has not felt baby moved (sic) since last night. Slight blood last night. Lower back pain). Review of Nursing Assessment documented at 2153 revealed "Abuse Indicators Trauma/Abuse Assessment Physical Abuse: Denies Verbal Abuse: Denies ..." Review of ED Provider Note documented at 2208 revealed "I went in to evaluate the patient. Patient tells me that she does not feel comfortable speaking to me without her guardian in the room. Guardian was left in the waiting room due to our current visit her (sic) policy. Will discuss with nursing to see if we can get the guardian on the phone." ED Provider Note documented at 2211 revealed "I went back in with 2 nurses to speak to the patient. I explained to her that since she was pregnant, she was considered emancipated. Our current visit our (sic) policy is to have no visitors in the room unless there is an exceptional reason for this. At this point, we offered to get her guardian on the phone so she could listen to everything that was going on. Patient refused to speak to me any further." Review of Nursing Note documented at 2214 revealed "Pt. refusing to speak w/ MD (with physician/medical doctor) if guardian cannot come back with her. This RN (Registered Nurse) verfies (sic) w/ charge RN and pt. explained of no visitor rules at this time and pt. is pregnant and does not need adult permisson (sic) at this time. Pt offered to phone call guardian and lace on speaker for MD assessment and care." Review of Provider Note documented at 2215 revealed "OF note, the triage nurse did note normal fetal cardiac tones, and fetal movement palpable during her initial exam." Review of Nursing Note documented at 2221 revealed "Pt. refused to speak with MD. MD asked what Pt decided and Pt stated 'I'm trying to figure it out'." Review of Provider documentation on ED timeline at 2227 revealed "ED Disposition set to Discharge." Review of Nursing Notes documented at 2228 revealed "Pt rang call light and stated she wanted discharge papers. MD at bedside and recommends Pt go to labor and delivery in Pinehurst." Review of Nursing Notes documented at 2233 revealed "...Mobility at Departure: Ambulatory Departure Mode: By self ... D/C (discharge) instructions reviewed with: Patient." Review of the After-Visit Discharge Instructions signature page revealed "I, the parent or guardian of Patient #6, on 09/21/21, received patient instruction and the after-visit summary was reviewed with me. I have read or had the instructions reviewed with me and understand the instructions given to me by Patient #6's caregivers. Patient Signature:_____" Further review of the Discharge Instructions signature page revealed the document was signed by Patient #6 on 09/21/21 with no documentation of the legal guardian's signature. Patient #6 was discharged to home from the ED on 09/21/2021 at 2234.

Interview on 12/15/2021 at 1615 with the Director of Risk Management revealed the legal guardian should have been allowed to be present with Patient #6 during the Provider exam, as the Patient was a 17 -year-old minor that was not emancipated and requested legal guardian presence. Interview revealed education on emancipation will be provided to all staff and providers immediately and then annually.

Interview on 12/15/2021 at 1625 with RN #4 (Registered Nurse) revealed RN #4 was not sure of the definition of an emancipated minor. Interview revealed RN #4 followed the Chain of Command and contacted the Charge Nurse and House Supervisor. Interview revealed that due to Patient #6 being pregnant and after reviewing the hospital policy the decision was made to not allow any visitors. Interview revealed RN #4 did not have any conversations with the legal guardian.

Interview on 12/16/2021 at 0900 with MD #3 revealed that when a pregnant minor presented to the ED, an adult/parent/guardian was not needed in order for the Provider to provide an examination and treatment. Interview revealed normally the Provider would allow visitors to see patients, but due to COVID precautions, visitation had been limited/stopped in the ED. Interview revealed the Provider offered to face-time the guardian by phone, but the Patient refused. Interview revealed the Provider misinterpreted the policy and thought Patient #6 did not need a legal guardian.

NC00182370