HospitalInspections.org

Based on observation, document review, and interview, it was determined that for 1 of 3 patients' (Pt. #1) clinical records reviewed for restraints and seclusion, the Hospital failed to ensure the use of seclusion was in accordance with the order of a physician by not obtaining a physician's order prior to the seclusion of a patient.

Findings include:

1. On 03/17/2022 at approximately 2:12 PM, the video footage for 3 South -Pediatric and Adolescent Girls Unit on 02/17/2022 between 02:40:14 PM to 03:03:09 PM, while Pt. #1 was in the seclusion/quiet room, was reviewed. The video footage from the Camera #1 - by the Nurses Station; Camera #2 - by the Seclusion/Quiet Room Vestibule; and Camera #3 - Camera inside the Quiet Room included the following:

-02:40:14 PM - Program Milieu Supervisor (PMS) (E #8) trying to advise Pt. #1 to go back into day room. 02:41:14 PM - PMS (E #8) dragging the patient (Pt. #1) body on the floor, by holding both hands of patient, into the seclusion/quiet room, while the RN (E #6) holding the door open. 02:41:29 PM - PMS (E #8) bending his knees and placing it by Pt. #1's head and shoulders. 02:41:34 PM - E #8 slams Pt. #1 to the corner of the quiet room and tries to close the door. 02:41:37 PM - E #8 tries to open the quiet room door, while the RN (E #6) observing the scene from behind. 02:41:42 PM - E #8 slams Pt. #1 again on to the floor in the quiet room. 02:41:45 PM - E #8 locks the quiet room door from outside and watches the patient through the glass window. 02:42:46 PM - Pt. #1 locked inside the quiet room while E #8 outside watching the patient. 02:43:56 PM - Pt. #1 continues to be left alone locked inside the quiet room and ripping off the padding on the wall. 02:46:04 PM - Pt. #1 continues to be left along locked inside the quiet room. 02:47:11 PM - RN from the unit outside the quiet room watching the patient from outside. 02:47:35 PM - RN from the unit comes with cup of water and pill to give to the patient. 02:50:04 PM - Mental Health Specialist (MHS) from the unit gets inside the quiet room and sits beside the patient. 02:54:27 PM - Pt. #1 hits the MHS inside the room. 02:54:39 PM - E #8 comes in with full force and arms in choking position rushing towards Pt. #1 inside the quiet room and pushes Pt. #1 on the bed. Holds the patient by both her shoulders and E #8 knees by Pt. #1's jaw. 02:55:05 PM - Code Yellow is called, and the physician on-call comes inside the quiet room, along with another staff and Unit manager. 02:55:30 PM - One staff by the left side of the Pt. #1's head, another staff by the right side, and one staff by the foot end holding both the legs. 02:57:37 PM - RN Nurse Manager by the door of the quiet room observing the incident. 02:57:58 PM - RN from the unit administers the medication on his left arm. 02:59:22 PM - Pt. #1 looks relaxed on bed one staff releases both the legs and 3:03:09 PM - Pt. #1 made to sit down at the edge of the bed.

-In summary, the video footage indicated PMS (E #8) used inappropriate techniques to hold Pt. #1 while Pt. #1 was aggressive. RN (E #6) was not seen helping the staff during the incident. Pt. #1 was placed in the locked seclusion/quiet room between 2:41 PM -2:47 PM (duration 6 minutes).

2. On 03/17/2022 at approximately 9:30 AM, Pt. #1's clinical record was reviewed. Pt. #1 was admitted to the Hospital's 3 South - Pediatric and Adolescent Girls Unit on 02/15/2022 at 2:26 PM, with a diagnosis of major depressive disorder. Pt. #1 was discharged home on 02/25/2022 at 9:00 AM. Pt. #1's clinical record included the following:

-The initial psychiatric assessment by Psychiatric Mental Health Nurse Practitioner (E #11) dated 02/17/2022 at 6:46 AM, included, " ...history of cutting and has cut in the last few days ...states that in January she tried to cut her wrists in a suicide attempt ...triggered by a comment that her ex-boyfriend made to her in January ...intrusive thoughts about it ...failing her classes ... out of school for 10 days ...problem with classmates ...thoughts of harming a classmate ...denied plan or intent ...patient [Pt. #1] sullen and withdrawn during interview ...delusions and bizarre behaviors ...denied anxiety, nervousness, and panic, denied SAO [sexually acting out] and aggression towards others ..."

-The clinical justification for initiation of seclusion or restraint note by Registered Nurse (E #6) dated 02/17/2022 at 2:55 PM included, " ...Physical Restraint: On Hold: Time In - 14:55 [2:55 PM] -Time out - 14:59 [2:59 PM] ...patient [Pt. #1] was in the hallway refusing to go the dayroom for group programming. Hallway staff offered to allow patient to sit in the room to calm down. Patient [Pt. #1] refused to go to the room and began cursing at hallway/nursing staff, " ...I am not fucking doing anything wrong! Y'all can get the fuck away from me!" Patient was walked to quiet room where they began to hit and kick staff ...pt. [Pt. #1] was combative with staff in the quiet room and making verbal threats ...[medications administered] placed on physical hold at 14:55 [2:55 PM] continued to verbally threaten staff and attempted to spit in staff's face. Patient [Pt. #1] was able to calm down and was released from hold at 14:59 [2:59 PM] ...all parties notified and paperwork was completed ..." Pt. #1's clinical record included the restraint flowsheet completed, less restrictive methods attempted, vital signs assessment one hour or post release ...face-to-face evaluation and summary by the Nurse Manager on the unit completed at 2:55 PM."

-Pt. #1's clinical record indicated Pt. #1 was aggressive, abusive, and was threatening staff. Pt. #1's clinical record included a physician's order for restraints/hold, but did not include a physician's order for placing Pt. #1 in seclusion.


3. On 03/17/2022 at approximately1:10 PM, the Hospital's policy titled, "Restraints and Seclusion" dated 04/2021 was reviewed and included, " ...3.0: Use of Less-Restrictive Measures: Prior to the use of a restraint or initiation of seclusion, when possible, attempts will be made to use less-restrictive measures to control the behavior that may potentially cause injury to the patient or others ...Telephone/verbal orders for restraints/seclusion may be received and recorded by an RN [Registered Nurse] ...if the attending physician ...did not order the restraints/seclusion ...he/she must be consulted as soon as possible (within 30 minutes) ..."

4. On 03/17/2022 at approximately 3:00 PM, 3 South Nurse Manager (E #3) was interviewed. E #3 stated that she was not sure why the patient was placed in the seclusion/quiet room locked without a physician order. E #3 stated that if any patient is placed in seclusion immediately within 5 -10 minutes a physician verbal order must be obtained and documented in the restraints/seclusion record. E #3 said, "I did not know the patient was in the seclusion room without physician order." E #3 stated that she has trained and educated the RN (E #6) who witnessed the event regarding timely reporting of the incident to the management.

5. On 03/18/2022 at approximately 9:45 AM, the Medical Physician (MD #1) was interviewed. MD #1stated that she assessed the patient on 02/17/2022 after the hold and does not recall patient complaining of any pain or injury. MD #1 stated that she does not give orders for seclusion or restraints.

6. On 03/18/2022 at approximately 9:50 AM, the Psychiatric Mental Health Nurse Practitioner (E #11) was interviewed. E #11 stated that typically they call for verbal orders for placing any patient in seclusion. E #11 stated that she does not recall if the staff called to place the patient (Pt. #1) in seclusion. E #11 stated that it is not appropriate to place the patient in seclusion without an order. E #11 stated that it is important to prioritize the safety of patient and staff.