HospitalInspections.org

Based on interview and document review, the hospital failed to ensure restraints were used in accordance with hospital policy for 2 of 10 patients reviewed P1 and P5, when staff placed the patients in violent restraints due to violent behavior, but staff documented them as being in non-violent restraints. Findings include:

Medical record review revealed that P1 was admitted to the hospital on 6/11/2019 with diagnoses that included Major Neurodegenerative Disorder with Behavioral Disturbances, Hypertension and Psychosis. The patient came from a local transitional care unit due to confusion and threatening behavior.

Nursing notes, dated 6/13/2019 revealed staff placed P1 in a lap belt restraint at 9:30 p.m. related to agitation, chasing and kicking staff and combative behavior. Staff held the patient in a manual hold at 1:33 a.m., for administration of an injected medication for behavior. The restraint order was changed from a violent restraint to a non-violent restraint at 0310 a.m. until 4:00 a.m.

Progress notes, dated 6/17/2019, revealed staff placed P1 in non-violent restraints at 4:00 a.m. related to disorientation, wandering, refusing assistance and charging at staff with her walker. De-escalation was attempted as well as PRN zyprexa (a medication to help the patient calm) which were ineffective. Because a non-violent restraint was initiated, there was no face to face assessment by a provider nor were the every 15 minute RN patient assessments completed. The patient was placed in a lap-belt restraint until 7:30 a.m.

During an interview on 10/23/2019 at 12:55 p.m., Registered Nurse (RN)-D stated P1's restraint was changed to a non-violent restraint on 6/13/2019 because she was cooperative, but not ready to be released from restraints. RN-D further stated that although the order was changed from a violent restraint to a non -violent restraint, the actual restraint remained exactly the same.

During an interview on 10/24/2019 at 10:55 a.m., RN-E stated that when a patient's order is changed from violent restraint to a non-violent restraint, the nurses no are longer required to assess the patient and document the patient's condition every 15 minutes, but instead only every 2 hours. Additionally, there is no face to face physican assessment required for non-violent restraints.

Medical record review revealed P5 was admitted to the hospital on 10/11/2019. P5's diagnoses included Lewy Body Dementia. Progress notes revealed staff placed P5 into a waist belt restraint on 10/14/2019 at 1:40 a.m. related to P5 being combative, head butting staff, and kicking staff. The waist belt remained in place until 5:10 a.m. At 2:23 a.m., P5's restraint order was changed from violent restraint to a non-violent restraint. Although P5 remained in the exact same restraint the entire time he was restrained, the every 15-minute RN checks were not completed after 2:23 a.m. until 5:10 a.m. when the restraint was discontinued, every 2 hour assessments were completed.

The policy titled Restraints/Seclusion - Management of Violent and/or Self-Destructive Behavior, dated effective 8/2018 and provided by hospital staff revealed:

When a restraint or seclusion is ordered, the patient must b assessed face-to-face by a practitioner within one hour of the initiation of the intervention...The face to face must address: The patient's immediate situation, The patient's reaction to the intervention, The patient's medical and behavioral condition, The need to continue or terminate the restraint or seclusion.

Discontinuation of Restraint/Seclusion: Once the unsafe situation ends, the use of restraint or seclusion should be discontinued. Restraint/Seclusion will be terminated at the earliest possible time...The decision to discontinue the intervention should be based on the determination that the need for restraint or seclusion is no longer present or that the patient's needs can be addressed using less restrictive measures.

The requirement for every 15 minute RN patient assessment for a patient in restraints for violent behavior was not present in the policy.