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Based on staff interview and record review, physical restraints were implemented on Patient #1 with no indication for their use or evidence of prior attempts at less restrictive measures to meet the patient's clinical needs or to protect the safety of the patient or others (For 1 of 11 patients). Findings include:

Per record review on 10/13/10, Patient #1 presented to the ED via ambulance, at 11:15 AM on 5/21/10, with a chief complaint of "Leg Pain". The note stated that EMS (Emergency Medical Services) had been called by a neighbor who had heard the patient screaming. The Ambulance record, dated 5/21/10 at 10:42 AM, identified the nature of the call as "Mental health issues".

Per review, an Incident Report completed by Security Services on 5/21/10 documented that Security personnel had been notified of Patient #1's pending arrival to the ED and that, upon arrival to the ED, the patient had been placed in 4 point restraints by Security personnel. Review of documentation by S#1 (sitter providing 1:1 monitoring of the patient ), indicated that at 11:18 AM, while restrained, the patient's 'Psychological Status' was agitated and threatening and revealed a descriptive note that the patient was "screaming .... "can't stand" restraints, swearing at staff." Subsequent documentation at both 11:30 AM and 11:45 AM again indicated the psychological status as agitated and threatening and a note stated that the patient "continues screaming". The ED Provider note, at 11:45 AM, stated that the patient presented with leg pain, and review of systems identified Psychiatric/Behavioral as "Positive for agitation". The note stated........."does not contemplate harming ....self...has not already injured self....does not contemplate injuring another person."

Record review further revealed that there was no assessment or documentation by nursing staff that described the need for, or implementation of, physical restraints as the least restrictive measure to assure the physical safety of the patient or others. There was also no evidence of the patient's clinical response to the intervention or identification of when the restraints were discontinued prior to the discharge of the patient at 12:59 PM.

During interview, on the morning of 10/14/10, Nurse #1 confirmed that s/he had provided care for Patient #1, during the 11:15 AM ED visit on 5/21/10. S/he stated that s/he could not recall whether or not the patient had been placed in restraints at the time of that particular visit, as s/he had provided care to Patient #1 on 2 of 3 visits to the ED on 5/21/10.

Based on record review and confirmed through staff interview, the medical record for Patient #1 lacked a clear description of the patient's behavior that warranted the need for the use of physical restraints (For 1 of 11 patients). Findings include:

Per record review Patient #1 presented to the ED via ambulance, at 11:15 AM on 5/21/10, with a chief complaint of "Leg Pain". The note stated that EMS (Emergency Medical Services) had been called by a neighbor who had heard the patient screaming. The Ambulance record, dated 5/21/10 at 10:42 AM identified the nature of the call as "Mental health issues".

Review of an Incident Report, completed by Security Services on 5/21/10, stated that Security personnel had been notified of Patient #1's pending arrival to the ED and that the patient had been placed in 4 point restraints, by Security personnel, upon arrival to the ED.
Review of documentation by S#1 (sitter providing 1:1 monitoring of the patient ), indicated that at 11:18 AM, while restrained, the patient's 'Psychological Status' was agitated and threatening and revealed a descriptive note that the patient was "screaming .... "can't stand" restraints, swearing at staff." Subsequent documentation at both 11:30 AM and 11:45 AM again indicated the psychological status as agitated and threatening and a note stated that the patient "continues screaming". The ED Provider note, at 11:45 AM, stated that the patient presented with leg pain, and review of systems identified Psychiatric/Behavioral as "Positive for agitation". The note stated........."does not contemplate harming ....self....has not already injured self....does not contemplate injuring another person."

There was no assessment or documentation by nursing staff that described the need for, or implementation of, physical restraints, as the least restrictive measure to assure the physical safety of the patient or others. There was also no evidence of the patient's clinical response to the use of restraints as an intervention or identification of when the restraints were discontinued prior to the discharge of the patient at 12:59 PM. In addition, there was no physician or other provider order for the use of restraints.

During interview, on the morning of 10/14/10, Nurse #1 confirmed that s/he had provided care for Patient #1,during the 11:15 AM ED visit on 5/21/10. S/he stated that s/he could not recall whether or not the patient had been placed in restraints at the time of that visit, as s/he had provided care to Patient #1 on 2 of 3 visits to the ED on 5/21/10. The lack of documentation describing an assessment of the patient's behaviors that warranted the need for the use of restraints was confirmed by the ED Clinical Nurse Specialist during interview on the morning of 10/14/10.

Based on record review and confirmed through staff interview the medical record for Patient #1 lacked documentation of an assessment of the condition or symptoms that warranted the use of physical restraints to assure the physical safety of the patient and others (For 1 of 11 patients). Findings include:

Per record review Patient #1 presented to the ED via ambulance, at 11:15 AM on 5/21/10, with a chief complaint of "Leg Pain". The note stated that EMS (Emergency Medical Services) had been called by a neighbor who had heard the patient screaming. The Ambulance record, dated 5/21/10 at 10:42 AM stated Nature of call; "Mental Health Issues".

Review of an Incident Report, completed by Security Services on 5/21/10, stated that Security personnel had been notified of Patient #1's pending arrival to the ED and that the patient had been placed in 4 point restraints, by Security personnel, upon arrival to the ED. Per record review, there were no nursing notes documenting symptoms indicating a need prior to the application of physical restraints to this patient. Review of documentation by S#1 (sitter providing 1:1 monitoring of the patient ), revealed that at 11:18 AM, after restraints were applied, the patient's 'Psychological Status' was agitated and threatening and revealed a descriptive note that the patient was "screaming .... "can't stand" restraints, swearing at staff." Subsequent documentation at both 11:30 AM and 11:45 AM again indicated the psychological status as agitated and threatening and a note stated that the patient "continues screaming". The ED Provider note, at 11:45 AM, stated that the patient presented with leg pain, and review of systems identified Psychiatric/Behavioral as "Positive for agitation". The note stated........."does not contemplate harming ....self.. has not already injured self....does not contemplate injuring another person."

There was no assessment or documentation by nursing staff that described the need for, or implementation of, physical restraints, as the least restrictive measure to assure the physical safety of the patient or others. There was also no documentation of the patient's clinical response to the intervention or assessment and identification of when the restraints were discontinued prior to the discharge of the patient at 12:59 PM. In addition, there was no physician or other provider order for the use of restraints.

During interview, on the morning of 10/14/10, the ED Nurse Clinical Specialist confirmed the lack of documentation regarding the use of restraints for Patient #1.