HospitalInspections.org

Based on staff interviews and review of medical records, policies and procedures, it was determined that in 1 out of 10 patients reviewed (patient #6), the patient was involuntarily secluded with insufficient justification when seclusion was initiated because the patient attempted to leave a locked unit (the emergency department " Crisis Intervention Pod " ).

The findings include:

Patient #6 was secluded after trying to leave the locked Crisis Intervention Pod of the hospital emergency department. On 1/18/15, beginning at 7:45 p.m., patient #6 was placed into involuntary seclusion for 3 hours and 45 minutes after she tried to leave the unit.

However, the medical record revealed insufficient justification for initiating the intervention. Documentation prior to initiating the intervention indicated that patient #6 was attempting to leave the unit, but there was no documentation demonstrating sufficient threat existed to use involuntary seclusion and there was no documentation that less restrictive measures were actually attempted (e.g. placing security staff at the door etc.) A progress note indicated that the " patient attempted to escape by pushing herself through the door while housekeeping was exiting the unit, more security notified and patient placed back in her room with locked door at 7:45 p.m.

Based on staff interviews and review of medical records, policies and procedures, it was determined that in 1 out of 10 patients reviewed (patient #6), the patient was involuntarily secluded with insufficient justification, when seclusion was initiated only because the patient attempted to leave a locked unit (the emergency department " Crisis Intervention Pod " ) and violent self-destructive behavior was not evident.

The findings include:

Medical record review revealed that patient #6 was secluded after trying to leave the locked Crisis Intervention Pod of the hospital emergency department. On 1/18/15, beginning at 7:45 p.m., patient #6 was placed into involuntary seclusion for 3 hours and 45 minutes after she tried to leave the unit.

However, the medical record revealed insufficient justification for initiating the intervention. Documentation prior to initiating the intervention indicated that patient #6 was attempting to leave the unit. Progress note documentation indicated that the " patient attempted to escape by pushing herself through the door while housekeeping was exiting the unit, more security notified and patient placed back in her room with locked door at 7:45 p.m. Flow-sheet documentation indicated that the reason for seclusion was " that the patient " attempted to escape while housekeeping exited the unit. " The flow-sheet documentation also indicated that alternatives failed because the patient was " rambling, hitting door, and kicking " but these behaviors were not described sufficiently to reach a level justifying involuntary seclusion and no specific alternatives were actually documented prior to initiation of involuntary seclusion.

Based on staff interviews and review of medical records, policies and procedures, it was determined that in 1 out of 10 medical record reviews (patient #6) was involuntarily secluded without any documented alternative measures attempted that might have been less restrictive.

The findings include:

Patient #6 was secluded after trying to leave the locked Crisis Intervention Pod of the hospital emergency department. On 1/18/15, beginning at 7:45 p.m., patient #6 was placed into involuntary seclusion for 3 hours and 45 minutes after she tried to leave the unit. A progress note indicated that the " patient attempted to escape by pushing herself through the door while housekeeping was exiting the unit, more security notified and patient placed back in her room with locked door at 7:45 p.m. Also, flow-sheet documentation indicated that the reason for seclusion was " that the patient " attempted to escape while housekeeping exited the unit. " An entry at 7:40 p.m. indicated that " security guards x3 with technician assisted to give medication to patient while sitting in chair, patient was cooperative and then returned to hostile behavior, door remains locked. " Although, the flow-sheet documentation also indicated that " alternatives failed " (preprinted into the form) no specific alternatives were actually documented prior to initiation of this episode of involuntary seclusion. Documentation on the form regarding patient #6 ' s behavior as " rambling, hitting door, and kicking " did not occur until after the patient was secluded.

Based on review of the medical record, it was determined that in 1 out of 10 medical record reviews (patient #1) the hospital failed to obtain an order for a manual hold to apply soft wrist restraints and then obtained an incorrect (non-violent) order for restraint use when the patient had in fact exhibited violent behavior. With the incorrect type of order (non-violent), hospital staff then failed to follow additional requirements for the management of restraints employed for violent behavioral need(s). This concern was evident for 1 of 3 patients reviewed (patient #1) for management of restraint and seclusion interventions.

The findings include:

The medical record revealed that during the evening of a 6/28/14 transfer to the Telemetry Unit, patient #1 became combative and was held by staff and placed into soft-wrist restraints by security and nursing staff. The review of patient #1's medical record revealed that there was no order for the physical hold by staff to apply the wrist restraints and that the wrist-restraint order inaccurately defined that the restraints were for non-violent need. With this inaccurate order, staff then failed to follow numerous regulatory requirements for managing restraints employed for violent behavior, and instead followed only the non-violent restraint requirements (see Federal tags A0174, A0175, and A0178).

























Based on review of the medical record, it was determined that in 1 out of 10 medical record reviews (patient #1) the hospital failed to obtain an order for a manual hold to apply soft wrist restraints and then obtained an incorrect (non-violent) order for restraint use when the patient had in fact exhibited violent behavior. With the incorrect type of order (non-violent), hospital staff then failed to follow additional requirements for the management of restraints employed for violent behavioral need(s). This concern was evident for 1 of 3 patients reviewed (patient #1) for management of restraint and seclusion interventions.

The findings include:

The medical record revealed that during the evening of a 6/28/14 transfer to the Telemetry Unit, patient #1 became combative and was held by staff and placed into soft-wrist restraints by security and nursing staff. The review of patient #1's medical record revealed that there was no order for the physical hold by staff to apply the wrist restraints and that the wrist-restraint order inaccurately defined that the restraints were for non-violent need. With this inaccurate order, staff then failed to follow numerous regulatory requirements for managing restraints employed for violent behavior, and instead followed only the non-violent restraint requirements (see Federal tags A0174, A0175, and A0178).

Based on medical record review, restraint and seclusion did not end at the earliest possible time when in one case, patient behavior was not monitored and documented; and in another case monitoring was done, but when the patient behaviors met criteria, seclusion still did not end. This concern was evident in 2 patients (#1 and #6) out of 3 patients reviewed where restraint or seclusion interventions were utilized, out od 10 total sampled patients.

The findings include:

1. The medical record revealed that patient #1 was placed into two point bilateral restraints on 6/28/14 at 9:20 p.m. for violent behavior but staff obtained an order for non-violent restraint use. While following the non-violent requirements, staff failed to conduct hourly nursing checks as defined in hospital policy and did not document frequent behavioral observations. Lacking these key behavior observations, the hospital did not demonstrate that restraints ended at the earliest possible time.

2. The medical record revealed that patient #6 was placed into involuntary seclusion at approximately 7:45 p.m. on 1/18/15. Behaviors were documented in 15-minute intervals in the behavioral flow-sheet, but the entries revealed that patient #6 was at times lying, sitting, sleeping, and/or mumbling from 8:15 p.m. through 11:30 p.m. (and possibly hallucinating at 10:00 p.m.) None of these behaviors justified continued use of involuntary seclusion for this more than 3 hour time period, and none of the behavioral observations prompted staff to end the seclusion episode. Thus, restraints did not end at the earliest possible time.

Based on review of medical records and hospital policy, in 3 of 3 patients (#1, #6, and #7) where restraint or seclusion interventions had been employed, the hospital failed to follow their policy related to this Federal requirement. (Hospital policy implements this Federal requirement for monitoring by mandating that nursing staff conduct one-hour checks on all residents in violent restraint or seclusion.)

The findings include:

1. Review of the medical record revealed that on 6/28/14 at 9:20 p.m. patient #1 was placed into restraints. Behavioral monitoring with 15-minute documentation of patient behavior(s) was not found completed and nursing checks were not completed hourly.

2. Review of the medical record revealed that on 1/18/15 at 7:45 p.m. patient #6 was placed into seclusion and seclusion continued until 11:30 p.m. No documentation of the hourly nursing checks was found in the medical record.

3. Review of the medical record revealed that on 1/19/15 patient #7 was placed into seclusion at 2:40pm and continued until 4:20 p.m. Documentation of the hourly nursing assessment due at 1540 (3:40pm) was not found in the medical record.

Based on a review medical records, the hospital failed to ensure that face-to-face evaluations were completed as required when restraints or seclusion were utilized for violent behavior. This concern was evident in 2 of 3 medical records reviewed where restraint or seclusion was employed, out of a total of 10 medical records reviewed.

The findings include:

1. Patient #6 was secluded two times after trying to leave the locked Crisis Intervention Pod of the hospital emergency department. First, on 1/18/15, beginning prior at approximately 7:45 p.m., patient #6 was placed into involuntary seclusion for 3 hours and 45 minutes after he/she tried to leave the unit. Second, on 1/19/15 beginning at 7:57 a.m. patient #6 was placed into involuntary seclusion again, this time lasting for 1 hour and 30 minutes. No documentation of the required face-to-face evaluation was found in the medical record for either of these two episodes of involuntary seclusion of patient #6.

2. Review of the medical record revealed that on 1/19/15 patient #7 was placed into seclusion that continued until 4:20 p.m. However, no documentation of the required face-to-face evaluation was found in the medical record for patient #7.

Based on observation and interview of the licensed emergency room nursing staff during a tour on 02/04/15 at 9:30AM of the Rapid Diagnostic Unit (RDU-an annex in the emergency department is used intermittently for patient observations and holds for overflow of emergency room patients), it was determined that not all medications are locked and secured in a safe manner to ensure their integrity.
In addition, observation and interview of the licensed emergency room nursing staff during the same tour, it was discovered that a check for readiness of the RDU emergency crash cart had not been conducted by staff for 02/04/15.
During the RDU tour the hallway was dim in light and the unit not in use at that time. Interview of the licensed emergency room nursing staff during the tour revealed that the unit had been open and used on 02/03/15.
In the RDU hallway was an alcove work area which contained an industrial (stainless steel) cubicle type, temperature controlled, and lockable medication refrigerator. Inspection of the refrigerator contents revealed that there were medications being stored such as: (2) 2 milliliters (ml) bottles Famotidine (anti-ulcer agent), (3) 25mls bottles of Diltiaze9anti-hypertensive agent), a box of (10) small bottles of Diltiazem, and (3) 50mls Cefazolin (antibiotic) intravenous antibiotic piggyback bags. During an interview with the emergency room nurse regarding whether the refrigerator was locked in between uses it was stated by the nurse that " No narcotics are in the refrigerator. " All medications must be kept secure to prevent illicit use and to prevent tampering.
Observation of the RDU emergency crash cart signature (log) check sheet and interview of the emergency room nursing staff during the tour, confirmed that the cart was last noted as checked on 02/03/15 when the unit was in use. The nursing staff reported that the hospital expectation is that emergency crash carts are usually checked every 24 hours. Failure to ensure the readiness of the emergency crash cart through every 24 hour checks, potentially places the patient at risk for a delay in treatment in the event of a respiratory or cardiac arrest.