HospitalInspections.org

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Based on interview, medical record review, and review of hospital policies and procedures, hospital staff failed to modify a patient's plan of care to include a long-term plan for discontinuing restraint use, as demonstrated by 1 of 11 patients reviewed (Patient #3).

Failure to develop a plan for behavior management and reduction of restraint use risks a failed discharge and a poor quality of life for the patient.

Findings included:

1. Review of the hospital's policy and procedure titled, "Restraint - Seclusion Policy", Policy #6516441 revised 06/11/19, showed that when patients were placed in restraints staff would update the patient's plan of care to include short-term and long-term goals for care.

2. On 08/06/19, the investigator reviewed the medical records for Patient #3, a 46 year-old patient currently receiving care at the hospital who had been admitted on 12/21/18. The patient had been diagnosed with autism and developmental disability. The patient was ready for discharge. However, hospital staff were unable to find placement due to the patient's periodic agitation and aggression.

3. On 08/06/19 at 9:45 AM during an interview with the investigator, a registered nurse caring for the patient (Staff #2) stated the patient was difficult to redirect and had been placed in a vest restraint on admission to prevent him from wandering outside of his room and becoming a danger to himself. The nurse stated the patient was occasionally put in bilateral wrist restraints to prevent him from taking off his vest over his head.

4. On 08/06/19 at 10:00 AM during an interview with the investigator, the unit's nurse manager (Staff #3) and charge nurse (Staff #4) stated that there was no plan for discontinuing the restraints.

5. Review of the patient's record showed that the patient's plan for care did not include a long-term plan for behavior management and discontinuing the restraints prior to the patient's discharge to the community.
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that orders for restraints were not written as a standing order and used on an as-needed basis, as demonstrated by 1 of 11 patients reviewed (Patient #3).

Failure to follow approved policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Review of the hospital's policy and procedure titled, "Restraint - Seclusion Policy", Policy #6516441 revised 06/11/19, showed that staff would make decisions for use of restraints and/or seclusion based on the patient's current behaviors. Decisions to use restraints and/or seclusion were not to be based on past seclusion or restraint history or solely on a history of dangerous behaviors. Restraint and/or seclusion orders were not be be written on an "as needed" basis.

2. On 08/06/19, the investigator reviewed the medical records for Patient #3, a 46 year-old patient currently receiving care at the hospital who had been admitted on 12/21/18. The patient had been diagnosed with autism and developmental disability.

2) On 08/06/19 at 9:45 AM during an interview with the investigator, a registered nurse caring for the patient (Staff #2) stated the patient was difficult to redirect and had been placed in a vest restraint on admission to prevent him from wandering outside of his room and becoming a danger to himself. The nurse stated the patient was occasionally put in bilateral wrist restraints to prevent him from taking off his vest over his head.

3) Review of the patient's record showed that on 07/27/19 an LIP had added an order for wrist restraints to daily orders for a vest restraint. The wrist restraint order was being used on an "as-needed" basis.
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that orders for restraints to manage violent or self-destructive behavior did not exceed four hours for adults and two hours for children and adolescents 9 to 17 years of age, as demonstrated by 5 of 11 patients reviewed (Patients #1, #2, #4, #5, #7).

Failure to follow approved policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Review of the hospital's policy and procedure titled, "Restraint - Seclusion Policy", Policy #6516441 revised 06/11/19, showed that duration of orders for management of violent/self-destructive behavior would be limited to 4 hours for adults and 2 hours for patients aged 9-17.

2. On 08/05/19 and 08/06/19, the investigator reviewed the medical records of eight patients currently in the hospital and three discharged patients who had been placed in restraints or seclusion during their hospital stay. This review showed the following:

a. Patient #1 was a 63 year-old patient currently receiving care at the hospital who had been admitted to the hospital's emergency department (ED) on 05/31/19 for treatment of agitation and acute respiratory failure. The patient had been diagnosed with post-traumatic stress disorder, depression, and schizoaffective bipolar disorder.

1) On 06/01/19 at 3:15 PM, the patient became violent and posed a danger to himself and others. ED staff placed the patient in two-point restraints. The patient remained in restraints until 06/02/19 at 11:37 AM. An LIP wrote an order for restraints due to violent behavior at 6:18 PM on 06/01/19. The next restraint order was written at 8:45 AM on 06/02/19. The restraint orders were not written every four hours as directed by hospital policy.

2) On 06/06/19, the patient again became a danger to himself and others. ED staff placed the patient in two-point restraints at 7:35 AM. The patient remained in restraints until 06/06/19 at 7:56 PM. An LIP wrote an order for restraints due to violent behavior at 8:16 AM and 11:55 AM. There were no further restraint orders after 11:55 AM. The restraint orders were not written at least every four hours as directed by hospital policy.

3) On 08/05/19 at 4:10 PM during an interview with the investigator, the nurse manager of the hospital's adult psychiatric unit (Staff #1) confirmed that staff had not followed the hospital's restraint policy and procedure while caring for Patient #1.

b. Patient #2 was a 48 year-old patient currently receiving care at at the hospital who had been admitted to the hospital's ED psychiatric holding area on 08/02/19. The patient had been involuntarily detained and was awaiting admission to the hospital's psychiatric unit for treatment of a personality disorder.

1) On 08/02/19, the patient became a danger to himself and others and was placed in four-point restraints at 10:10 PM. An LIP wrote an order for restraints due to violent behavior at 10:16 PM. The next restraint order was not written until 3:17 AM. The restraint orders were not written every four hours as directed by hospital policy.

2) On 08/03/19 at 4:03 PM, the patient was released from restraints and placed in seclusion due to risk of elopement. An LIP wrote an order for seclusion at 4:03 PM and 6:00 PM. The next seclusion order was not written until 11:43 PM. The restraint orders were not written every four hours as directed by hospital policy.

3) On 08/05/09 at 10:40 AM during an interview with the investigator, the nurse manager of the hospital's adult psychiatric unit (Staff #1) confirmed that staff had not followed the hospital's restraint and seclusion policy while caring for Patient #2.

d. Patient #4 was a 28 year-old patient currently receiving care at the hospital who had been admitted on 08/03/19 for treatment of sepsis and drug-induced psychosis. The patient became violent after admission and was placed in four-point restraints at 10:45 PM. The patient remained in restraints until 08/05/19 at 5:00 PM.

1) Review of the patient's record showed that an LIP had written restraint orders at least every four hours from 08/03/19 at 10:50 PM until 08/04/19 at 7:50 PM. The next orders were written on 08/05/19 at 2:23 AM, 9:43 AM, 9:56 AM, and 3:26 PM. The restraint orders had not been written at least every four hours as directed by hospital policy.

2) On 08/06/19 at 10:50 AM during an interview with the investigaor, the unit's nurse manager (Staff #6) confirmed that staff had not followed the hospital's restraint and seclusion policy while caring for Patient #4.

e. Patient #5 was a 13 year-old patient currently receiving care at the hospital who had been admitted on 07/29/19 for surgical treatment of a brain tumor. The patient became violent after surgery and was placed in four-point restraints on 08/04/19 at 7:00 AM. The patient remained in four-point restraints until 08/05/19 at 5:00 PM.

1) Review of the patient's record showed that an LIP had written restraint orders every two hours from 08/04/19 at 7:26 AM to 08/04/19 at 11:15 PM. The next restraint orders were written on 08/05/19 at 2:45 AM, 4:39 AM, 6:30 AM, and 9:48 AM. The orders were not written every two hours as directed by hospital policy.

2) On 08/06/19 at 11:20 AM during an interview with the investigator, the staff nurse caring for the patient (Staff #7)
confirmed that staff had not followed the hospital's restraint and seclusion policy while caring for Patient #5.

h. Patient #7 was an 11 year-old discharged patient with developmental disability and fetal alcohol syndrome who had been admitted on 05/01/19 for treatment of aggressive behavior.

1) The patient became aggressive and a danger to herself and others and was placed in four-point restraints on 05/02/19 at 9:15 AM. The patient's record included an order for seclusion but not for restraints. The patient was released from restraints at 9:53 AM. The patient again became aggressive and a danger to herself and others and was placed in four-point restraints on 05/07/19 at 10:15 AM. The patient's record included an order for seclusion but not for restraints. The patient was released from restraints at 10:48 AM.

2) On 08/06/19 at 2:15 PM during an interview with the investigator, the Director of Procedural Services (Staff #5) confirmed that staff had not followed the hospital's restraint and seclusion policy while caring for Patient #7.
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that restraints or seclusion were discontinued at the earliest possible time based on the patient's behavior, as demonstrated by 1 of 11 patients reviewed (Patient #1).

Failure to follow approved policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Review of the hospital's policy and procedure titled, "Restraint - Seclusion Policy", Policy #6516441 revised 06/11/19, showed that restraints and/or seclusion would be discontinued when the patient met identified criteria for release.

2. On 08/05/19, the investigator reviewed the medical records of Patient #1, a 63 year-old patient currently receiving care at the hospital who had been admitted to the hospital's emergency department (ED) on 05/31/19 for treatment of agitation and acute respiratory failure. The patient had been diagnosed with post-traumatic stress disorder, depression, and schizoaffective bipolar disorder.

a. On 06/10/19 at 1:48 PM, the patient was placed in a vest restraint. The patient's records indicated he was confused and disoriented at that time. The records indicated that the patient's condition improved and that he was "alert, oriented, and calm" on 06/10/19 at 8:00 PM. The records showed the patient was in a vest restraint even though his record indicated he was alert, oriented, and calm from 06/10/19 at 8:00 PM through 06/12/19 at 10:00 PM. The patient was not released from the restraint when he met release criteria.

b. On 08/05/19 at 4:10 PM during an interview with the investigator, the nurse manager of the hospital's adult psychiatric unit confirmed that staff had not followed the hospital's restraint policy and procedure while caring for Patient #1.
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that patients restrained for violent, self-destructive behavior were monitored every 15 minutes as directed by hospital policy, as demonstrated by 1 of 11 patients reviewed (Patient #1).

Failure to follow approved policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Review of the hospital's policy and procedure titled, "Restraint - Seclusion Policy", Policy #6516441 revised 06/11/19, showed when patients were placed in restraints and/or seclusion due to violent/self-destructive behavior, staff would monitor and document the patient's condition every 15 minutes in the patient's medical record.

2. On 08/05/19 , the investigator reviewed the medical records of Patient #1, a 63 year-old patient currently receiving care at the hospital who had been admitted to the hospital's emergency department (ED) on 05/31/19 for treatment of agitation and acute respiratory failure. The patient had been diagnosed with post-traumatic stress disorder, depression, and schizoaffective bipolar disorder.

On 06/04/19, the patient became a danger to himself and others. A licensed independent practitioner wrote an order for restraints due to violent behavior at 2:33 PM. ED staff placed the patient in four-point restraints at 3:00 PM. The patient remained in restraints until 11:29 PM. ED staff documented the patient's condition every two hours instead of every 15 minutes as directed by hospital policy.

3. On 08/05/19 at 4:10 PM during an interview with the investigator, the nurse manager of the hospital's adult psychiatric unit (Staff #1) confirmed that staff had not followed the hospital's restraint policy and procedure while caring for Patient #1.
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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that patients were evaluated face-to-face by a licensed independent practitioner or trained RN within 1 hour after initiation of the restraints or seclusion, as demonstrated by 3 of 11 patients reviewed (Patients #1, #6, #7).

Failure to follow approved policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Review of the hospital's policy and procedure titled, "Restraint - Seclusion Policy", Policy #6516441 revised 06/11/19, showed when patients were placed in restraints and/or seclusion due to violent/self-destructive behavior, a trained RN or licensed independent practitioner (LIP) would complete a face-to-face assessment of the patient within the first hour of restraint application.

2. On 08/05/19 and 08/06/19, the investigator reviewed the medical records of eight patients currently in the hospital and three discharged patients who had been placed in restraints or seclusion during their hospital stay. This review showed the following:

a. Patient #1 was a 63 year-old patient currently receiving care at the hospital who had been admitted to the hospital's emergency department (ED) on 05/31/19 for treatment of agitation and acute respiratory failure. The patient had been diagnosed with post-traumatic stress disorder, depression, and schizoaffective bipolar disorder.

1) On 06/06/19, the patient became a danger to himself and others. ED staff placed the patient in two-point restraints at 7:35 AM. The patient remained in restraints until 06/06/19 at 7:56 PM. The patient's record lacked evidence of a face-to-face evaluation by a trained RN or LIP within one hour of restraint application.

2) On 08/05/19 at 4:10 PM during an interview with the investigator, the nurse manager of the hospital's adult psychiatric unit (Staff #1) confirmed that staff had not followed the hospital's restraint policy and procedure while caring for Patient #1.

b. Patient #6 was a 30 year-old discharged patient who had been admitted on 06/01/19 for treatment of major depression and suicidal ideation.

1) The patient became a danger to himself and was placed in four-point restraints on 06/14/19 at 3:10 PM. There was no evidence of a face-to-face evaluation by a trained RN or LIP within one hour of restraint application.

2) On 08/06/19 at 2:15 PM during an interview with the investigator, the Director of Procedural Services (Staff #5) confirmed that staff had not followed the hospital's restraint policy and procedure while caring for Patient #6.

c. Patient #7 was an 11 year-old discharged patient with developmental disability and fetal alcohol syndrome who had been admitted on 05/01/19 for treatment of aggressive behavior.

1) The patient became aggressive and a danger to herself and others and was placed in four-point restraints on 05/02/19 at 9:15 AM. There was no evidence of a face-to-face evaluation by a trained RN or LIP within one hour of restraint application.

2) On 08/06/19 at 2:15 PM during an interview with the investigator, the Director of Procedural Services (Staff #5) confirmed that staff had not followed the hospital's restraint policy and procedure while caring for Patient #7.
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