HospitalInspections.org

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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that staff ordered appropriate restraints for patients demonstrating violent or self-destructive behaviors that jeopardized the immediate physical safety of the patient, staff, or others for 3 of 3 patient records reviewed (Patients #1, #2 and #3).

Failure to ensure that staff order appropriate restraints for patients demonstrating violent or self-destructive behaviors that jeopardize the immediate physical safety of the patient, staff, or others places patients at risk for deterioration in behavioral and medical status and poor outcomes.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint and Seclusion for Patient Safety," policy number 900.5274, last revised 07/22, showed that non-violent, non-behavioral restraint (NVB) is used to ensure the physical safety and integrity of medical interventions. Restraint for violent or self-destructive behavior (VSD) prevent movement due to severely aggressive, destructive, violent or suicidal behavior that places the patient or others in imminent danger when non-physical interventions would be ineffective. The policy showed that responsible licensed practitioner or trained registered nurse (RN) shall perform and document a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of restraint or seclusion. The face to face assessment will include the patient's immediate situation, the patient's reaction to the intervention, the patient's medical and behavioral condition, and the need to continue or terminate the restraint or seclusion.

2. On 12/09/22 at 12:00 PM, the investigator and the Patient Safety Consultant (Staff #2) and the Medical Specialties Nurse Manager (Staff #9) reviewed the medical records of 3 patients restrained for violent or self-destructive behavior. The review showed the following:

a. On 10/07/22 at 2:57 PM, nursing staff obtained a verbal order to place Patient #1 in non-violent, 4-point soft limb holders. The reason for the restraint order showed "patient unable to prevent actions that may cause harm to self/others." Nursing note documentation showed that prior to restraint application, Patient #1 was agitated, belligerent and trying to leave the medical unit. The investigator found no documentation that a medical hold was initiated or a capacity evaluation was performed to determine if the patient was appropriate to leave against medical advice.

b. On 11/10/22 at 11:18 PM, the provider ordered 4-point neoprene locking restraints for violent or self-destructive behavior after Patient #3 demonstrated aggressive behavior and verbalized threats toward other patients and staff in the emergency department (ED). On 11/11/22 at 2:52 AM, the provider placed a new order for non-violent 4-point soft restraints. The order showed that the reason for restraint placement included the patient lacks awareness of safety implications or behaviors due to impaired judgement and/or cognition, patient unable to prevent actions that may cause harm, and attempts to remove medically necessary equipment or devices. Nursing documentation showed that the patient remained verbally aggressive and continued to threaten staff with physical harm while awake.

c. On 11/22/22 at 10:17 PM, nursing staff obtained a verbal order for violent self-destructive 4-point neoprene locking restraints after Patient #2 demonstrated aggressive behavior and verbalized threats toward other patients and staff in the ED. On 11/23/22 at 4:46 AM, the nurse entered a verbal order for non-violent 2-point soft restraints for lack of awareness of safety implications or behaviors due to impaired judgement and/or cognition and the patient is unable to prevent actions that may cause harm to self/others. Nursing documentation showed that the clinical justification for the continued restraint use included impulsive behavior, screaming, and yelling.

3. At the time of the record review, Staff #2 and Staff #9 confirmed the investigator's finding that non-violent/non-behavioral restraints were ordered when documentation showed that the patients were restrained due to violent, threatening and/or combative behaviors.
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that nursing staff document attempted alternatives to manage behaviors of restrained patients every 2 hours for 2 of 3 patient records reviewed (Patients #1 and #3).

Failure to ensure that nursing staff document attempted alternatives to manage behaviors of restrained patients every 2 hours places patients at risk for deterioration in behavioral and medical status and poor outcomes.

Findings included:

1. Document review of the hospital's policy and procedure titled, "Restraint and Seclusion for Patient Safety," policy number 900.5274, last revised 07/22, showed that when restraints are applied, the registered nurse (RN) will assess the patient in person every 2 hours to assess clinical need for continued restraint use. The assessment will include an attempt at alternative measures to restraint use. The nurse will document the alternative measures attempted and the patient's response.

2. On 12/09/22 at 12:00 PM, the investigator and the Patient Safety Consultant (Staff #2) and the Medical Specialties Nurse Manager (Staff #9) reviewed the medical records of 3 patients restrained for violent or self-destructive behavior. The review showed the following:

a. On 10/07/22 at 3:00 PM, Patient #1 was placed in 4-point soft-limb restraints following an attempt to leave the hospital. Nursing documentation showed that between 10/07/22 at 5:00 PM and 10/09/22 at 12:00 PM, staff failed to document any attempts for less restrictive alternatives as required by hospital policy.

b. Nursing flowsheet documentation showed that on 11/11/22, Patient #3 was in bilateral soft wrist restraints from 2:52 AM to 12:30 PM. Nursing documentation showed that the patient was asleep from 3:15 AM to 6:00 AM and from 8:00 AM to 9:00 AM. The investigator found no evidence showing that staff attempted to evaluate any less restrictive alternatives while Patient #3 was restrained as required by hospital policy.

3. At the time of the record review, Staff #2 and Staff #9 confirmed the investigator's findings.
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