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Based on hospital policy and procedure review, medical record review, and staff interview, the hospital staff failed to identify the need for a chemical restraint order for 1 of 1 chemically restrained patients sampled. (Patient #1)

The findings include:

Review of hospital policy "Restraint and Seclusion", last revised 03/2018 revealed "...DEFINITIONS:... Chemical Restraint: Is the inappropriate use of a sedating psychotropic drug to manage or control behavior. A medication used to manage the patient's behavior or restrict the patient's freedom of movement that is not considered a standard treatment or dosage for the patient's condition is a chemical restraint. Medication should not be used at any time as a restraint..."

Closed medical record review on 02/23/2021 revealed a 80 year old male patient admitted to the hospital on 02/06/2021 with a primary diagnosis of Pneumonia due to severe acute respiratory syndrome coronavirus 2. Record review revealed the patient was alert and oriented upon admission. Review of "Neurological Assessment" on 02/07/2021 at 0630 revealed "Acute change from baseline, Impaired cognition, Inappropriate shifting of attention." Review of Physician Progress notes on 02/07/2021 at 1200 revealed "Subjective: Patient was seen and evaluated at bedside this morning. I was informed by the nursing staff, patient was confused early hours of this morning and wanted to leave the hospital against medical advice, he became combative when he could not leave the hospital given his altered mental state. He pointed a pocket knife to the security personnel and Police was called. Patient sustained a head injury while he was resisting medical staff... He was given 10 mg Zyprexa (antipsychotic medication)..." Review of the Medication Adminstration record revealed Zyprexa 10mg administered at 0725. Review of the Medication Administration Record revealed Zyprexa 10 mg administered at 1545 and Haldol 5mg (antipsychotic medication) administered at 1640. Review of Progress Notes on 02/07/2021 at 1948 revealed "Patient noted to become more and more agitated. He slapped this nurse two occasions. Patient making racial slurs to this nurse and CNA (Certified Nursing Assistant). Patient swinging at staff and even hit his sister at bedside. (Named MD) notified and she is to order medications." Review revealed no Physician order for chemical restraints.

Interview on 02/25/2021 at 1411 with RN #2 revealed she was with Patient #1 the afternoon of 02/07/2021. Interview revealed the patient became confused, combative, swing and hitting at the nurses. Interview revealed we called security to assist. Interview revealed medications were administered to help the patient calm down.

Interview on 02/24/2021 at 1415 with the Nursing Supervisor revealed she responds to all restraint episodes to get the process going. Interview revealed she obtains the orders, reviews the orders so the staff have what they need for the restraint episode. Interview revealed she was not aware the medications given for the patient's behavior was a chemical restraint. Interview revealed she felt like the event was a medical intervention due to the patient's confusion.

Based on policy and procedure review, medical record review, incident reports and staff interviews, hospital staff failed to obtain a physician order for seclusion in 1 of 1 seclusion patients reviewed (# 1).

The findings include:

Review of hospital policy "Restraint and Seclusion", last revised 03/2018 revealed "...DEFINITIONS:...B. "Seclusion" is the involuntary confinement of a patient alone in a room or an area where the patient is physically prevented from leaving. For example, a staff member standing in front of the unlocked door of a patient's room with the intent of preventing the patient from leaving the room has placed the patient in seclusion. Seclusion may only be used for the management of violent or self-destructive behaviors...A. Methodology..2. Document the physician's order for restraint on the Physician's Order Sheet for Restraints or Seclusion..."

Closed medical record review on 02/23/2021 revealed a 80 year old male patient admitted to the hospital on 02/06/2021 with a primary diagnosis of Pneumonia due to severe acute respiratory syndrome coronavirus 2. Record review revealed the patient was alert and oriented upon admission. Review of "Neurological Assessment" on 02/07/2021 at 0630 revealed "Acute change from baseline, Impaired cognition, Inappropriate shifting of attention." Review of Physician Progress notes on 02/07/2021 at 1200 revealed "Subjective: Patient was seen and evaluated at bedside this morning. I was informed by the nursing staff, patient was confused early hours of this morning and wanted to leave the hospital against medical advice, he became combative when he could not leave the hospital given his altered mental state..." Record review revealed no nursing notes documented regarding event. Record review revealed no physician order for seclusion.

Review of security incident report on 02/07/2021 at 0642 revealed "I had a call to go to room 562. The Patient was being hostile when I got there they was holding the door [sic]. I got a hold of the door and ask the nurse to back up. I told him to calm down. I am going to open the door to talk to him..."

Interview on 02/24/2021 at 0930 with RN (Registered Nurse) #1 revealed she was Patient #1's nurse on the night of 02/06/2021 when he was admitted alert and oriented and on 02/07/2021 when he woke up and was acutely confused. Interview revealed the patient was demanding to leave the hospital. Interview revealed the patient stated, "I know my rights." Interview revealed she did not want the patient to leave the hospital alone and confused. Interview revealed she called the patient's family to let them know the situation. Interview revealed she also had hospital security called. Interview revealed she and the nursing assistant had the patient go back in to his room and held the door until security arrived. Interview revealed when security arrived he stood in front of Patient #1 's door so he could not exit. Interview revealed she did not realize holding or blocking the patient in the room was a seclusion event, she just wanted to keep the patient and staff safe. Interview revealed the patient would not wear a mask and was wanting to leave the hospital and it was cold and he did not have a ride home.

Interview on 02/24/2021 at 1020 with SO #1 (Security Officer) revealed he was called to the 5th floor for a patient event. Interview revealed upon arrival to the unit the staff was holding the door to Patient #1 room so he could not exit. Interview revealed the patient was screaming "I am going to kill all of you". Interview revealed he stood in front of the door and tried to speak to the patient. Interview revealed he was told the patient wanted to go home but the staff did not want him to leave due to not wearing a mask and waiting for family to arrive.

Based on policy review, medical record review and staff interview, facility staff failed to ensure a time limited order was written for the use of violent restraints for 1 of 1 sampled violent restraint records reviewed. (Patient #1)

The findings include:

Review of hospital policy "Restraint and Seclusion", last revised 03/2018 revealed "PROCEDURE:...B. Authorization and Ordering of Restraints...C . Restraint orders must be dated and times when signed by the physician, and include: 1) criteria for release; 2) type of restraint used; 3) reason for restraint; 4) and specified duration of restraint order.. Violent Track Maximum time for violent restraint: 4 hours for 18 and up..."

Closed medical record review on 02/23/2021 revealed a 80 year old male patient admitted to the hospital on 02/06/2021 with a primary diagnosis of Pneumonia due to severe acute respiratory syndrome coronavirus 2. Record review revealed the patient was alert and oriented upon admission. Review of "Neurological Assessment" on 02/07/2021 at 0630 revealed "Acute change from baseline, Impaired cognition, Inappropriate shifting of attention." Review of Progress Notes on 02/07/2021 at 1948 revealed "Patient noted to become more and more agitated. He slapped this nurse two occasions. Patient making racial slurs to this nurse and CNA (Certified nursing assistant). Patient swinging at staff and even hit his sister at bedside. (Named MD) notified and she is to order medications." Review of Physician Progress Notes on 02/08/2021 at 1032 revealed "Patient was seen at bedside, he was alert and oriented. 1-2 daughter was at bedside. overnight[sic] patient was on restraints because he hit 2 nurses and his daughter. Restraints have been removed as patient is no longer confused." Record review revealed Patient #1 was placed in right and left soft limb restraints at 1740 on 02/07/2021 and released on 02/08/2012 at 1015 (16 hours and 35 minutes) for his behaviors. Review of a physician's order dated 02/07/2021 at 1625 revealed an order for "Non-Violent or Non Self Destructive Restraint Physician Orders." Review of the restraint order revealed no four hour time limited order placed for the restraint.

Interview on 02/24/2021 at 1415 with the Nursing Supervisor revealed she responds to all restraint episodes to get the process going. Interview revealed she obtains the orders, reviews the orders so the staff have what they need for the restraint episode. Interview revealed she felt like the event was a medical intervention due to the patient's confusion. Interview revealed the restraint order obtained was for a non violent episode because of her "misinterpretation" of the policy.

NC00174391