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Based on review of 16 medical records, review of policies and procedures, and an interview with the Emergency Department (ED) Manager on 4/5/2016, it was determined that the hospital failed to appropriately identify the rationale or type of restraint used (violent and assaultive behavior vs. non- violent) and as a result failed to failed to document restraint assessments every 15 minutes as required for patient #2.

Patient #2 arrived to the ED by ambulance on the evening of 4/4/2016 and was diagnosed with alcohol intoxication. The ED nurse documented at 20:00 that she "assumed care of patient. Patient swings arms at staff. Agitated. Put on soft restraints. Alert and arousable."

The 'Restraint/Seclusion Flowsheet' was initiated by the ED nurse at 2010. The nurse documented the reason for the soft wrist restraints as "the patient was unable to control activities or self-movement to protect patients, staff or others from harm/danger." The standardized physician order sheet for ordering violent vs. non-violent behavior does not clearly indicate the clinical justification (behavior) that was used to determine violent vs. non-violent patient restraint situations. The nurse's note clearly documented that the patient was "swinging arms at staff" and that the patient was "agitated." The restraint flowsheet also noted that the patient was "combative" at 20:10 when the restraints were applied.

During an interview with the ED manager, the medical record for patient #2 was reviewed with the restraint orders and documentation was discussed. The ED manager reported that the only time violent criteria would be used by nursing staff is when hard (Neoprene) restraints would be used to restrain a patient. Therefore, the requirements for restraint documentation is based on the type of restraint (soft wrist vs. Neoprene]) used and not on the patient's presenting behavior.

Review of the medical record for patient #2 also revealed that the patient received one intramuscular dose of Versed (a medication used for or indicated for anesthesia, sedation, seizures, or severe agitation) at 20:00, a second dose of Versed at 22:10 and an intramuscular dose of Haldol (an antipsychotic medication that may be used for agitation) at 23:40. The patient's vital signs were documented during triage at 2000, then at 22:02 and 23:40. The patient behavior was documented on the restraint flowsheet at 20:10, 22:02, 23:40, 01:00, 03:05, and 05:10 (restraints were removed at 05:30). There was no nursing documentation for patient #2 to indicate that a reassessment was performed to assess the effectiveness of the Versed and Haldol medications after it had been administered.

The hospital's policy, 'Management of restraint use for non-violent and violent patients' which was last updated in March 2016, documents that non-violent restraints " may be used for patients who are not able to follow directions. These patients may attempt to dislodge tubes, sutures, dressings, drains, attempt unsafe ambulation, or are unable to control activities or self-movement." This policy limits the use of violent restraints for patients who are violent, aggressive, or self-destructive presenting immediate, serious danger to her/his safety or that of others. The section of policy defining violent behaviors and use of restraints indicated that soft cuffs, Neoprene hard cuffs, vests, or leather restraints are the types of devices used for restraining violent patients. This was in contrast to the statement by the ED manager stating that only hard (Neoprene) cuffs are used for violent patients. Because the staff failed to follow the hospital's own policy and did not document patient #2 as being in violent restraints, even though the documentation indicated he was violent, they did not document behavior assessments every 15 minutes, and did not document continuously monitoring of patient #2 after being administered medications to sedate with the intent to calm while being in restraints.

Failure to identify and document the behavior warranting the use restraints, and failure to document restraint assessments for combative/violent patients every 15 minutes while being restrained physically and receiving medications to sedate and/or calm, places patients at risk for delayed treatment of injury and/or decline in physical assessment findings.

Based on a review of calendar year 2015 QAPI data and interviews with staff during the survey on 4/5/16, it was determined that the hospital failed to collect data on restraint and seclusion use that was of sufficient quality to determine patient outcomes or to permit any analysis of the quality of care given to patients in restraint.


Data collected in CY15 regarding restraint use listed restraint use rates and the restrained patient days rate but did not differentiate between restraints used for violent behavior vs. non-violent, did not identify any seclusion episodes, and did not identify factors such as time of day or hospital unit which would have enabled a more in-depth analysis of the care given during restraint episodes. The hospital also collected data on the compliance of restraint-related documentation in the electronic medical record. Failure to collect restraint use data of sufficient depth and granularity meant that the hospital could not use the data to ensure that restraints were being used appropriately, to identify needed staff education, or to determine patient outcomes. In addition, opportunities and strategies to reduce restraint use were not identified.