HospitalInspections.org

Based on document review and interview, it was determined that the Hospital failed to ensure to protect and promote each patient's rights related to restraint use. Therefore, the Condition of Participation, 42 CFR 482.13 Patient Rights was not met.

Findings include:

1. The Hospital failed to ensure that the use of violent behavioral restraint was in accordance with the order of a physician/licensed practitioner. See A-0168

Based on document review and interview, it was determined in 4 of 10 patients' (Pt #5, Pt #6, Pt #7, Pt #8) clinical records reviewed for utilization of restraints, the Hospital failed to ensure that written modification of the patient's plan of care was completed.

Findings include:

1. The Hospital's policy titled, "HSHS Restraint and Seclusion Policy" (effective 12/2020) was reviewed 12/2/21. The policy noted, "...Documentation:...B. The individualized patient plan of care will include restraint care management...".

2. The clinical record of Pt. #5 was reviewed on 12/2/21 at 1:00 PM. Pt. #5 was admitted to the Hospital on 11/25/21 due to gun shot wound. The clinical record indicated that Pt. #5 was placed in non-violent restraints on 11/26/21 related to being put on the ventilator. The clinical record lacked written modification of Pt. #5's care plan regarding utilization of restraints.

3. The clinical record of Pt #6 was reviewed on 12/2/21 at 1:45 PM. Pt #6 was admitted to the Hospital on 11/14/21 due to Respiratory Insufficiency (COVID pneumonia). The clinical record indicated that Pt #6 was placed in non-violent restraints on 11/29/21 related to pulling at lines. The clinical record lacked written modification of Pt #6's care plan regarding utilization of restraints.

4. The clinical record of Pt #7 was reviewed on 12/2/21 at 2:30 PM. Pt #7 was admitted to the Hospital on 11/2/21 due to Colon Cancer and Respiratory Failure. The clinical record indicated that Pt #7 was placed in non-violent restraints on 11/28/21 related to pulling at lines (feeding tube). The clinical record lacked written modification of Pt #7's care plan regarding utilization of restraints.

5. The clinical record of Pt #8 was reviewed on 12/2/21 at 3:15 PM. Pt #8 was admitted to the Hospital on 9/8/21 due to ingestion of bleach. The clinical record indicated that Pt #8 was placed in violent restraints on 9/14/21 related to combative behavior. The clinical record lacked written modification of Pt #8's care plan regarding utilization of restraints.

6. An interview was conducted on 12/3/21 at 10:00 AM, with the Assistant Manager of Adult ICU (E #10). E #10 agreed with the above findings, stating, "the care plans should have been modified following utilization of restraints".

Based on document review and interview, it was determined that for 2 of 10 clinical records (Pt #2, Pt #3) reviewed for violent behavioral restraint use, the Hospital failed to ensure that the use of restraint was in accordance with the order of a physician/licensed practitioner.

Findings include:

1. The Hospital's policy titled "HSHS Restraint and Seclusion Policy" (effective 1214/21) was reviewed on 12/2/21. The policy noted, "RESTRAINT PROCEDURE:...8. Orders for violent behavioral restraint or seclusion are limited to the duration listed below. Re-evaluation by a RN (Registered Nurse) trained on initiation and assessment of restraints for the need to continue violent behavioral restraint, a new physician's order (phone order is acceptable) must take place: a. 4 hours for adults 18. b. 2 hours for children and adolescents ages 9-17..."


2. The clinical record of Pt #1 was reviewed on 12/02/2021 at 1:00 PM. Pt #1, an adolescent, arrived via ambulance to the ED on 11/03/21 with a chief complaint of "Homicidal/ Psychosocial Complaints." Pt #1 was admitted to the Emergency Department on 11/03/2021 and was discharged from the Emergency Department 11/09/2021. On 11/5/2021 at 11:45 AM, an ED Registered Nurse (E # 5) note stated "Pt continues to scream, attempting to elope, and became physically aggressive to staff while trying to contain pt in room. Zyprexa (antipsychotic) intramuscularly given and 4 point soft restraints applied with assistance of security and RN's." Another ED RN (E #7) stated Pt #1 was removed from restraints at 11/5/2021 at 2:22 PM. The record lacked orders and renewal order from a physician for the violent restraints.

3. During the review, the Accreditation Readiness Manager (E #4) and ED Nurse Manager (E #9) stated that the facility had "identified some concerns related to Pt #1 during the chart review and have started an action plan."


4. On 12/03/2021 at 11:30 AM a interview was conducted with E #5 (RN who initiated the restraints on 11/05/21), confirmed the the information in Pt #1's clinical record. E # 5 stated "I did not get an order for the restraint as I assumed there was an order and I didn't need to get a new one."

5. On 12/3/2021 at 1:00 PM an interview was conducted with E #7 (RN who assumed care of Pt #1 and removed the restraints on 11/5/2021). E #7 confirmed the information in Pt #1's clinical record. E #7 stated "on 11/5/2021, I was shocked that Pt #1 was still in restraints as the patient had been sleeping. I removed the restraints at on 11/5/2021 at 2:22 PM and got (Pt #1) a meal tray."

6. The clinical record of Pt #3 was reviewed on 12/2/21 at 12:30 PM. Pt #3, an adult, arrived to the ED (Emergency Department) 11/28/21 exhibiting uncooperative and violent behavior related to intoxication. The record included a physician's order, dated 11/28/21 at 11:54 AM, for 4-point soft (violent) restraints, continuous for up 4 hours, due to danger to self and others. Restraint flowsheets indicated that Pt #3 was put in violent restraints with 15 minute checks beginning 11/28/2021 at 2:09 PM and continuing until Pt #3 was moved to ICU at 4:20 PM. The record lacked a renewal order from a physician for the violent restraints, which was due 4 hours from the initial order at 3:54 PM.

7. An interview was conducted on 12/2/21 at 1:30 PM, with the Assistant Manager Adult ICU (E #10). E#10 stated that violent restraint orders (for adults over 18 years of age) are good for up to 4 hours. E#10 stated that after 4 hours, the original orders must be renewed or a new order placed. E #10 verified the findings in Pt #3's chart.