HospitalInspections.org

Based on record review, policy review, document review and interviews the hospital failed to ensure staff followed policy and obtained a written restraint order within one hour after the nurse received a verbal order for restraints and failed to renew orders for restraints every four hours for 1 of 6 patient (Patient 3). This deficient practice has the potential to place patients at risk for being improperly restrained.


Findings Include:


Review of Facility Policy title, "Restraints: Violent Behavior Or Seclusion" reviewed 10/2020 showed, ...

"Restraint - Any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely; or Chemical Restraint - A drug or medication that is used as a restriction to manage the patient's behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition." ...12.) The use of restraint or seclusion is: 12.1 In accordance with a written modification to the patient's plan of care; and 12.2 Implemented in accordance with safe and appropriate restraint techniques and in accordance with state law.

Initiation of Restraints or Seclusion

1. The order includes: 1.) The type of restraint, 2.) for locked Velcro restraints the order must specify 4-point restraints; 3.) duration; 4.) If a verbal order was given to initiate restraints, the physician must sign the verbal order and complete a written order which must take place within 1 hour

2. The patient for whom restraint or seclusion is used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others, is seen face-to-face as soon as possible, but no later than one (1) hour after the initiation of the intervention by a: Physician, or a Registered Nurse or Physician Assistance who has been trained in accordance with the training requirements specified in this policy.

Continuation of Restraints or Seclusion

1. All telephone or written orders are time limited as follows:

1.1 4 hours for Adults (18 years of age or older)

2. Orders may be renewed according to time limits for a maximum of 24 consecutive hours

3. Before the expiration of the original order for restraints or seclusion the physician must evaluate the patient in person. The physician in person evaluation includes:

3.1 Working with staff to help the patient regain control
3.2 Revising the patient plan of care, treatment, and services as needed
3.3 Providing a new order, if necessary...


Patient 3

Review of Patient 3's discharged medical record showed that Patient 3 presented to the emergency department on 10/19/22 with chief complaint of Suicidal Ideation with a plan and Altered Mental Status (AMS). The record showed Patient 3 had periods of anxiety, agitation, and aggression.

Patient 3's medical record showed that an initial order for soft 4-point restraints was entered into the computer system on 10/20/22 at 12:54 AM for a start date and time of 10/19/22 at 9:30 PM.

Review of Staff F, Doctor of Osteopathy (DO), History and Physical (H & P) dated 10/19/22 at 6:25 PM showed, "Patient 3 immediately started flailing and was not rational, would not listen to what we were saying. Patient 3 was given Ativan 2 milligram (MG), after a few moments she calmed down. A bit later Patient 3 woke up and sat up and was talking with her father. At some point Patient 3 became upset and started flailing again, kicking, screaming and not being unreasonable. Patient 3 struck at least two staff members. Patient 3 was given additional Ativan 2 MG and well as Zyprexa 10 MG. It was not immediately effective, so we were forced to physically restrain her with soft restraints for her protection as well as for the staff."

Review of Staff G, RN nursing progress notes dated 10/19/22 at 9:05 PM showed Patient 3 had increased agitation, yelling for her parents.

Review of Staff J, RN nursing progress note dated 10/19/22 at 9:10 PM showed "Patient 3 pulled out her IV and started hitting herself. Her father started holding her and trying to calm her and the agitation was increasing between Patient 3 and her father. The not showed Patient 3 was trying to get out of bed, had legs between railing. The nurse, her father, and CNA tried to get patient correctly in bed.

Review of Staff J, RN nursing progress note dated 10/19/22 at 9:20 PM showed "Patient rolled over the bed railing onto the floor. Security and RN attempted to help get Patient 3 in bed. Patient 3 started fighting swinging arms, leaned back on bed, and kicked security in his right knee. Patient 3 hit Staff J RN in the left side of the head. Four-point restraints applied for patient and staff safety."

Review of Staff G, RN nursing progress note dated 10/19/22 at 9:30 PM showed "verbal order received to administer 2 MG Ativan IV and place patient in 4 - point soft restraints. Order status canceled and the RN is unable to enter the set to document at this time"

Review of Staff H DO physician progress note dated 10/20/22 at 10:56 AM showed "Patient verbally and physically combative with sitter. 4-point restraint still in place. Patient 3 attempting to get out and cause physical harm to healthcare providers responding to screaming agitated patient. Geodon 10 MG administered, and Ativan 2 MG IV administered. Patient 3 spitting and trying to bite staff. Spitting hood applied. Ketamine 100 MG IV administered for acute excited delirium/psychosis."

Review of Staff I, RN nursing progress note dated 10/20/22 at 1:20 PM showed, "Patient 3 screaming at staff, thrashing in bed. Patient got her left hand free of restraint. When ED staff went into room, Patient 3 grabbed at staff, pinched staff and attempt to bite Staff H, DO and spit at RN."

Review of Staff H DO physician progress note dated 10/20/22 at 4:34 PM showed "situation with father escalated at bedside. Patient 3 is upset, verbally abusive and remains a threat physically whenever healthcare staff go near. Police consulted about their ability to assist with medication administration, they stood at bedside while Zyprexa 10 mg intramuscularly (IM) was administered. At present, patient able to be verbally de-escalated and decision made to withhold reapplying restraints."

Review of Staff H, DO physician progress note dated 10/20/22 at 5:50 PM showed "Patient still in 4 -point restraint after hourly face to face evaluations given continued to be a physical threat to self and other."

Review of Patient 3's medical records showed that the restraint order was renewed four times on 10/20/22 at 12:18 AM, at 5:50 AM, greater than 5 hours from the original order, at 10:55 AM, greater than 5 hours and 5 minutes from the previous order and then again at 3:51 PM, 4 hours and 56 minutes from the previous order.


During an interview on 11/03/22 at 12:48 PM with Staff J, Registered Nurse (RN) charge nurse, stated that she did not have a discussion with Patient 3's parents regarding the restraints. She stated that Patient 3 did not get put into restraints until she hit security and Patient 3 also and Staff J, RN Charge on the side of the head.

During an interview on 11/04/22 at 9:22 AM with Staff G, Registered Nurse (RN) stated that she got the order for the restraints on 10/19/22 and Patient 3 was in restraints at 9:30 PM. Staff G, RN stated that Staff F, DO initiated the restraint order. Staff G, RN stated that Patient 3 was in restraints all night with standard nursing checks.


During an interview on 11/04/22 at 11:45 AM with Staff F, Doctor of Osteopathy (DO) stated that Patient 3 said that she did not want to stay and that she wanted to go home. Patient 3 was told she would have to stay and initially she was okay with that. Staff F DO, stated that Patient 3 became more agitated and irritated as time progressed. Staff F, DO stated "I gave an order for Patient 3 to have a dose of Ativan." Staff F, stated that Patient 3 was still wide awake and belligerent, attempted to pull out her intravenous (IV) line. Patient 3 was flopping around, hitting the wall, and starting to fight. Patient 3 kicked the security guard in the knee and kicked and hit other staff. Staff F DO, stated that an order for Zyprexa was written and the patient was put into restraints.

The hospital failed to ensure staff obtained a written restraint order within one hour after the nurse received a verbal order for restraints and restraints were not renewed every four hours per hospital policy for Patient 3 placing the patient at risk for improper use of restraints.