HospitalInspections.org

Based on an onsite two-day survey of 1/8 and 1/9/2014, it is determined that Condition of Patient Rights was not met as evidenced by the following findings:
? failed to send resolution letters to #1 and #7 grievances as related to A-123;
? failed to allow patient #6 to refuse treatment as related to A-131; failed to justify restraint/seclusion for psychiatric patients #2, 3, 4, 5, 6, and 7 in the emergency department related to A-154;
? failed to meet requirements for restraint/seclusion orders as found with A-168;
? failed to meet requirements for a physician face to face within one hour and after 24 hours of restraint/seclusion as related to A-172 and A-179; and
? failed to meet requirements for training intervals for security staff.

Based on review of the hospital grievance policy and grievance files, no resolution letter is found for grievance #1 and #7 of 10 reviewed grievance files


Hospital policy for " Complaints and Grievances: Patients " (approved 7/10/2012) reveals in part, " A grievance received from a patient or patient ' s representative is responded to in writing ... " review of grievance files #1 and #7 reveals no resolution letters were sent to the complainants. Therefore, the hospital failed to meet regulatory requirement for resolution of grievances.

Based on a review the hospital patient rights pamphlet, and 10 patient records, it is revealed that patient #6 was given fluids, which he had expressly refused.

The Hospital Patient Rights and Responsibilities pamphlet which is given to patients on admission reveals "You have the right to - Refuse treatment to the extent permitted by law."

Patient #6 is a middle-aged male who presented to the emergency department (ED) via police escort while on an emergency petition, following referral by a crisis center for paranoid ideation with thoughts of harming others. An emergency petition (EP) compels an emergency department to conduct an evaluation of a patient for dangerousness to self or other. However, an EP does not remove basic patient rights to refuse treatment. Only two physicians with a finding that the patient lacks capacity to make decisions can give treatment against a patient's will.
Based on review of the medical record it was revealed that a physician assessment of 0834 states in part that patient #6 has "severely impaired judgment." A physician note of 1020 states that patient #6 had an elevated CK (creatinine kinase) of 1891.0 units. Creatinine Kinase is an enzyme found primarily in muscle tissues. High levels can indicate muscle destruction from various causes. Fluid administration is a treatment to make the excretion of creatinine kinase through the kidneys less damaging. Additionally, patient #6 could not be medically cleared for admission to a psychiatric facility until his CK levels came down. The physician wrote in part, "Patient needs IV hydration for elevated CK. He declined fluids despite extensive discussions. Will require restraint for fluids."
An RN note of 1106 states "Pt refused medication administration. I attempted to give the patient choices about time and site of administration pt refused. Dr. __ notified of refusal and security called for restraints." The physician ordered 4-point restraints in order to give fluids against patient #6's expressed refusal, and without certifying a lack of capacity to make his own medical decisions.
Patient #6 was placed in 4 point hard restraint at 1021 and given three 1000 ml bags of NACL ( Sodium chloride) 0.9%. Patient #6 remained in 4-point restraint until 2045, a total of more than 10 hours.
Not-withstanding that the treatment for the elevated creatinine kinase was appropriate, the hospital failed to respect patient #6's right to refuse that treatment.

Based on a review of hospital restraint/seclusion policy, hospital patient rights and responsibilities notification, interview and 10 patient records, it is revealed that 1) all reviewed records for psychiatric patients #2, 3, 4, 5, 6, and 7 presenting to the hospital, received orders for violent restraint/seclusion regardless of behaviors, which failed to demonstrate imminent dangerousness, 2) staff used restraint to administer IV fluids to objecting patient #6.

The Hospital and Patient Care Management for Using Restraint policy (approved 9/25/2012) was reviewed by the surveyor and it revealed that the " Procedure - Initiation on Restraints: 1. Alternatives to restraints will be attempted and the patient's response will be documented in the Electronic Medical Record (EMR) Restraint form."

The policy also states conditions for the use of restraints for violent patients as "Behavior that becomes aggressive, presenting an immediate, serious danger to the patient's safety or that of others."


Interview with an ED representative regarding the behavioral requirements justifying orders for restraint/seclusion revealed that staff uses the immediate history, which brought the patient to the ED to determine dangerousness. Review of records revealed that even if real-time assessments indicated no imminent dangerousness, patients were restrained/secluded. The representative believes that if the hospital intention is not to allow the patient to leave the room, a seclusion order had to be in place. While the definition of seclusion includes the involuntary confinement of a patient alone in a room who is physically prevented from leaving that room, the hospital did not take the patient's voluntary compliance into account, nor the requirement for a real-time behavioral assessment for justification of imminent dangerousness.

Further it was determined that staff revealed was the belief that an Emergency Petition for evaluation automatically required restraint/seclusion orders due to the chance of elopement. However, record review found that, restraint/seclusion orders are applied, regardless of Emergency Petition status.

It is revealed that generally within ? hour of ED presentation, an order for violent restraint/seclusion is written for all patients presenting with psychiatric concerns. Some patients were further found to have "seclusion" specified in the order, and some were found to have the restraint order of "All-side-rails-up' specified, yet these patients were also secluded according to nursing documentation. Additionally in practice, any seclusion/restraint order means that the patient remains in their ED bed with a monitoring sitter, and as generally observed, with the room door open. Patients observed in the ED during survey, appeared comfortable, and were also allowed to have visitors by the bedside, albeit, restraint/seclusion was being utilized inappropriately.

On record review, alternatives to restraint/seclusion interventions were based on potential behaviors or behaviors demonstrated prior to the patient's ED presentation as follows:
Patient #2 is a female in her 30's presenting to the emergency department (ED) via private automobile following suicidal ideation for one weeks duration. Patient #1 was not on an Emergency Petition for evaluation, and was denied a current plan of self harm on entry to care, though other documentation revealed an intention to act on her suicidal thoughts. A sitter was placed with patient #2.
A Restraint/Seclusion Violent order was placed within approximately one hour of patient #1's entry to care, though Patient #1 remained quiet and cooperative throughout care. A nursing note of 2319 states in part, "New admit to ED, no alternatives attempted at this time. Pt expressed SI (suicidal ideation). Seclusion initiated for pt. safety." Additionally, nursing documented "All side rails up. Seclusion."
Patient #2 continued to remain calm and cooperative in the hospital bed with the door to her room open, and an observing sitter in attendance. Additionally, during the seclusion, patient #2 was noted to be talking alternately with the friend who brought her to the hospital and family members who came to her bedside. This would not be possible if patient #2 was truly demonstrating imminent harm to herself.
Four subsequent continuation orders for violent restraints/seclusion were written throughout patient #2's time in the ED into the following day and all orders were equally unjustified as patient #2's behaviors did not rise to actual attempts to harm herself. However, nursing documentation states "Continue restraint. Restraint in use is least restrictive way to protect patient safety."
In practice, patient #2 was given appropriate care with close observation to maintain her safety prior to transfer for continued treatment, though no alternatives were tried, and seclusion/4-side-rails-up was neither behaviorally justified nor warranted.
Patient #3 is a female in her 30's who presented to the ED on Emergency Petition accompanied by police, and on the day of onsite survey, following a physical confrontation with family members. Patient #3 complained of a history of depression but denied suicidal ideations. Patient #3 was noted by nursing to be calm, cooperative and appropriate. However, an order for "Restraint/Seclusion Violent " specifying " Seclusion " was entered approximately one half hour after patient #3 ' s arrival. A self harm risk screening one half hour later, stated "No" desire on the part of patient #3 to harm herself, though other documentation states that she was secluded for being "Harmful to others " and "Emergency petition signed by police, per police pt was violent with family at home." Approximately three quarters of an hour following seclusion, patient #3 is documented at "Sitting up in bed reading." A face to face evaluation notes the patient's reaction to Restraint-Seclusion as "Ineventful" (sic) and the patient's immediate situation as "Resting peacefully presently." Based on this assessment, the physician wrote to "Continue " the orders, which had gone on for 2-hours by that point.
Patient #4 is a middle-aged female who presented to the ED via emergency medical services on the day of survey due to voices telling her to harm herself and others. Patient #4 was noted by nursing as calm, cooperative and appropriate. A sitter was placed at bedside and an order for "Restraint/Seclusion Violent" was placed within one half hour of her ED presentation.
Nursing alternatives are listed as "Counseling, Reality orientation, Redirected." However, patient #4 presented with no behaviors that would be considered violent, assaultive or self injurious to warrant seclusion.
Patient #5 presented to the ED via private car following her complaints of hearing voices telling her to harm herself or others, though she denied wanting to harm herself or others. The ED physician emergency petitioned patient #5, and then made her involuntary for inpatient treatment. Patient #5 was noted as cooperative and a 1:1 sitter was placed for close observation. An order for violent restraint/seclusion was placed at 2235.
Nursing alternatives state "No alternatives attempted at this time. Pt hearing voices. Seclusion and 1:1 observations initiated for pt. safety."
A physician note states in part, "Pt remains cooperative, understands is awaiting placement ...At this point possible acceptance at (hospital) pending. Pt resting comfortably, no distress. Seclusion restraints renewed." Patient #5 remained under seclusion orders throughout her ED stay of more than 13 hours, without any behaviors posing imminent danger.
Patient #6 is a middle-aged male who presented to the emergency department (ED) via police escort on an emergency petition, following referral by a crisis center for paranoid ideation with thoughts of harming others.
An order for Restraint/Seclusion Violent, specifying "All Side Rails Up" was written at 0524. Nursing documentation states that not only were the side rails up, but nursing was documenting seclusion as well for which there was no order. At 1021, after patient #6 refused IV fluids, an order for "Hard x 4" restraints was written. Patient #6 was placed in 4-point restraints, and IV fluids were administered despite his refusals to treat a high creatinine kinase level which would have prevented him from being medically cleared for transfer.
An order for "All Side Rails Up" was written at 1243 following the IV infusion. However, nursing kept patient #6 in 4-point restraint until 2045, a total of more than 10 hours with no justification to do so. All together, patient #6 was continuously under restraint/seclusion orders for 30 hours.
Patient #7 is a male in his 50's who presented to the ED by private car at 1321 due to suicidal ideations with plan. He is noted by nursing as "Patient is calm at this time. Asking for food."
A nursing note entered at1859 reveals seclusion was initiated at 1245. A nursing note states a justification of "Harmful to self." An order for Restraint/Seclusion Violent was written at 1400. Patient #7's specific behaviors at initiation are noted by nursing to be "rambling and talking." Alternatives attempted were 1:1 intervention, Reality orientation, visually supervised. Patient #7 had all side rails up, and was simultaneously secluded. No behaviors are noted warranting restraint or seclusion.
Following a psychiatric evaluation, two Physician Certifications were signed, and an inpatient placement was arranged. At 2323 patient #7 stated he wanted to leave, but when seeing security, stated he would remain calm. Seclusion continued through the following day at 0645 for a total of 18 hours, including the day before.
Based on all documentation, the hospital failed to justify the subsequent seclusion, and/or restraint of patients #2, 3, 4, 5, 6, and 7 who presented to the emergency department, and kept orders on these patients throughout their stay in the ED until discharge. The hospital failed to meet regulatory requirements for assessment of alternatives to restraint and seclusion.

Based on a review of restraint and seclusion polices, and 10 patient records, 1) patient #1 received no order for a 3-point violent restraint, 2) Patient #6 had an order for all side rails up for more than two hours prior to an order being obtained; patient #6 was also documented as being in seclusion though no order was written, and was kept in 4-point restraint for hours beyond the time when the order expired; 3) Patient #7 was secluded for more than one hour prior to an order being obtained.

Hospital restraint and seclusion policies reviewed reveal in part that " An order for (restraint/seclusion) is obtained prior to or concurrently with application. " A review of medical records revealed the following:

Patient #1 was a middle-aged male who presented via ambulance to the emergency department (ED) at 1245 following complaints of syncope and a temporary loss of consciousness, severe abdominal pain and shortness of breath (SOB). Patient #1 was pale and diaphoretic on presentation.
While hospital staff worked quickly to evaluate and treat patient #1, he became combative within 15-minutes of presentation. Security was called to place patient #1 in restraint due to combativeness and the disruption of his IV's. According to the record, patient #1 was placed in restraint for medical purposes, though 3-point hard (violent) restraints were used. At 1303, patient #1 became pulseless. Though no time is revealed for when the restraints were taken off, a physician record addendum of 10/21/2013 reveals "Please note that pt was preventing us from placing IV lines, ripping off his O2 mask and not following directions. Restraints were required to inable (sic) us to provide medical care. The restraints were briefly used and were removed immediately when pt went into cardiac arrest." No order is found in the record for the restraints which were applied to patient #1. No actual times associated with the application or removal of the restraints is found.
Patient #6 is a middle-aged male who presented to the emergency department via police escort following referral by the crisis center for paranoid ideation with thoughts of harming others. According to the record, restraint flow documentation was initiated on patient #6 ' s entry into the ED room at 0308, though no actual order was entered until 0524, more than two hours later.
An order for violent restraints was made specifying "All-side-rails-up" though an RN note of 0333 indicates that patient #6 was also considered to be in "Seclusion." No order for seclusion appears in the record.
Nursing documented less-restrictive-alternatives as "Patient brought in by police as emergency petition." This means that based solely on the EP, patient #6 was restrained and secluded.
An updated physician note of 1020 reveals that patient #6 declined fluids for a medical condition despite extensive discussions. The physician wrote "Will require restraint for fluids." Patient #6 was placed in 4 point hard restraint at 1021 and given IV fluids against his will. When the IV was completed, the physician wrote an order at 1243 indicating a change of restraint back to 4 raised side rails. However, nursing continued the 4-point restraints until 2045, a total of 10 hours. Patient #6 was kept under restraint/seclusion orders for a total of 30 hours.
Patient #7 is a male in his 50's who presented to the ED by private car at 1321 due to suicidal ideations with plan. He is noted by nursing as "Patient is calm at this time. Asking for food."
A nursing note for 1245 reveals seclusion was initiated at that time, however, no order is found until 1400. The nursing note states a justification of "Harmful to self." An order for Restraint/Seclusion Violent was written at 1400 indicating "Seclusion" as the intervention. No justification is found for this order. Seclusion continued through the following day at 0645 for a total of 18 hours from the 1245 initiated the day before.
Based on documentation, the hospital failed to write orders for restraint/seclusion interventions, failed to write timely orders for those interventions, and staff failed to follow the orders as they were written.

Based on hospital restraint policy and review of record #6 of 10 patient records, it is revealed that patient #6 was under restraint orders for 30 hours, yet received no restraint focused face-to-face assessment after 24 hours.

Hospital restraint policy for Time Limitation & Renewal reviewed on 1/8/2014 by the surveyor states in part, "2. Orders may be renewed according to the above time limits for a maximum of 24 hours."

Patient #6 is a middle-aged male who presented to the emergency department via police escort following referral by the crisis center for paranoid ideation with thoughts of harming others. According to the record, restraint flow documentation was initiated on patient #6 ' s entry into the ED room at 0308, though no actual order was entered until 0524, more than two hours later.
Patient #6 had continuous orders for All-bedrails-up excepting a period from 1021 to 1243 when he was placed on 4-point restraints to give IV fluids against his will. Documentation from nursing indicated that patient #6 was also in seclusion evidenced by flow documentation of "All wrists/ankles, Other: Seclusion."
Patient #6 was under restraint orders for an approximate total of 30 hours from 10/17/13 at 0524, and required a face-to-face on 10/18/13 at that approximate time. However, no face-to-face is found in the record which meets face-to-face requirements. A physician note of 0459 states "Pt cooperative but pacing in his room. Pt offered medication to help him relax, but he states he is OK." The fact that patient #6 was still under restraint orders is not mentioned, and a new order for All Side Rails Up was written at 0645. The hospital failed to assess patient #6 following 24 hours of continuous restraint.

Based on a review of hospital policy for restraint/seclusion and 10 patient records, it is revealed that face-to-face restraint/seclusion evaluations for patients #3 and 4 do not meet the requirements for continuation of the intervention, and F2F evaluations for patients #2, 5, 6, 7, and 9 do not meet evaluation requirements.

Patient #2 is a female in her 30's presenting to the emergency department (ED) via private automobile following suicidal ideation for one weeks duration. Patient #1 was not on an Emergency Petition for evaluation, and denied a current plan of self harm on entry to care, though other documentation reveals an intention to act on her suicidal thoughts. A sitter was placed with patient #2.
A Restraint/Seclusion Violent order specifying seclusion was placed within approximately one hour of patient #1's entry to care, though Patient #1 remained quiet and cooperative throughout care.
The physician evaluation of 2311 reveals that patient #2 was "Cooperative, Mood and affect: Flat." No documentation other than the order for seclusion reveals a physician face-to-face evaluation.
Patient #3 is a female in her 30's who presented to the ED on Emergency Petition accompanied by police during the onsite survey, following a physical confrontation with family members. Patient #3 complained of a history of depression but denied suicidal ideations. Patient #3 was noted by nursing to be calm, cooperative and appropriate. An order for "Restraint/Seclusion Violent" was entered approximately one half hour after patient #3's arrival, which specified seclusion. A physician face to face notes the patient reaction to Restraint-Seclusion as "Uneventful" and the patient's immediate situation as "Resting peacefully presently." Based on this assessment, the physician wrote to "Continue" the orders even though the face-to-faced yielded no justification to do so.
Patient #4 is a middle-aged female who presented to the ED via emergency medical services on the day of survey due to voices telling her to harm herself and others. Patient #4 was noted by nursing as calm, cooperative and appropriate. A sitter was placed at bedside and an order for "Restraint/Seclusion Violent" was placed within one half hour of presentation. A Face to Face is noted in the record at 1214 with a reaction of restraint-seclusion of "Pt happy to be here, is comfortable waiting for therapist to come, feels safe. The physician stated to continue the intervention, even though the face-to-face yielded no justification to do so.
Patient #5 presented to the ED via private car following her complaints of hearing voices telling her to harm herself or others, though she denied wanting to harm herself or others. The ED physician emergency petitioned patient #5, and then made her involuntary inpatient treatment. Patient #5 was noted as cooperative and a 1:1 sitter was placed for close observation. An order for violent restraint/seclusion was placed at 2235. While the physician saw patient #5 at 2310, no face-to-face is noted in the record which addresses the requirements of the face-to-face.
Patient #6 is a middle-aged male who presented to the emergency department via police escort following referral by the crisis center for paranoid ideation with thoughts of harming others. According to the record, restraint flow documentation was initiated on patient #6 ' s entry into the ED at 0308, though no actual order was entered until 0524. Physician documentation fails to meet face-to-face requirements. Patient #6 was placed in 4 point hard restraint at 1021 and given fluids against his will. Patient #6 again required a face-to-face based on the the more restrictive order. However, no face-to-face is noted in the record.
Patient #7 is a male in his 50's who presented to the ED by private car to the ED at 1321 due to suicidal ideations with plan. He is noted by nursing as "Patient is calm at this time. Asking for food."
A nursing note not entered until 1859 reveals seclusion was initiated at 1245, however, no order is found until 1400. A physician exam began at 1359, but does not meet all the requirements of the face-to-face, nor does the physician mention the fact that restraint/seclusion orders were written.
Patient #9 is an adolescent female who presented to the ED due to intoxication. A Restraint/Seclusion Violent order was written at 1002, and again at 1242 specifying seclusion as the intervention for combative behavior. A physician assessment of 0956 noted patient #9 as "uncooperative and belligerent." While the physician saw patient #9 at the initiation of seclusion, requirements for the patient response to seclusion and whether to continue restraint are not found, nor is any physician reference to the seclusion intervention.

Based on hospital policy, interview, and documentation of initial training/retraining for 30 security officers who restrain patients, it is revealed that 13 of officers have no evidence of training, and retraining for 13 officers fails to meet competency standards and hospital policy for annual retraining.

Review of the hospital policy for Patient Restraint by a surveyor on 1/8/2014 reveals in part, "Staff will be trained and able to demonstrate competency in one or more of the following as part of orientation and on an annual basis in accordance with their position, job duties, and responsibilities: hospital policy, strategies to identify triggering circumstances, alternatives and less restrictive interventions, proper application and use ... " The hospital uses Crisis Prevention Institute (CPI) training.

Interview with security officer #8 by the surveyor reveals that he received training in restraints, but could not identify how often retraining is performed. Review of officer #8's training documentation reveals a last training date in 2010.

The hospital has at least 24 full time security officers including management, with 6 prn (as needed) officers. A request to review restraint orientation training and retraining revealed various documents with no concrete accounting of orientation or retraining for all officers as follows:

The hospital states that three officers are new and have not yet received training. However, an audit of all documented training against a current officer roster reveals 10 full-time and 3 prn (as needed) officers have no evidence of training. Officers #5, 6, 11, 12, 14, 15, 16, 17, and 18 received their last Crisis Intervention and restraint training in 2007. Officer #19 received his last training in 2008; and officers #7 and 10 received their last training in 2009.

Based on these numbers, the hospital fails to promote safe restraint practices when it fails to train and maintain training for hospital security officers who may be required to assist in restraint and seclusion interventions.

Based on review of the hospital quality Clinical Dashboard used to audit restraint/seclusion events, it is determined that deficient practices related to restraint/seclusion are not identified, and not used for change and improvement.

The hospital has a quality Clinical Dashboard for restraint/seclusion, for which 10 violent and 10 nonviolent restraints/seclusions are monitored each month. Questions related to restraint/seclusion appropriately match regulatory directives such e.g., " Based on the order for violent restraint, is there documentation to support the evidence of violent behavior? " However, as documented in A-154, multiple psychiatric patients are restrained/secluded without justification.

Therefore, the Clinical Dashboard for restraint/seclusion, fails to identify data which can be used for change and improvement.

Based on a request for electrocardiogram (EKG) strips associated with a patient code, it is revealed that the hospital is unable to produce those EKG strips indicating an incomplete medical record for patient #1.

A request for EKG strips associated with a code for patient #1 who went into asystole resulted in the hospital inability to locate those strips. Therefore, the hospital failed to maintain a complete record.