HospitalInspections.org

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Based on interview, review of hospital video monitoring, and document review, the hospital failed to adopt, implement, review and revise patient care policies and procedures that address restraints.

Failure to adhere to hospital policies and procedures related to restraints places patients at risk for physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. The hospital failed to ensure that staff followed its policy and procedure for restraint use.

Cross-reference Tag A-0154

2. The hospital failed to ensure that staff modified patient care plans when patients were placed in restraints.

Cross-reference Tag A-0166

3. The hospital failed to ensure that a licensed provider wrote orders for restraints according to hospital policy.

Cross-reference Tag A-0168

4. The hospital failed to ensure that patients were evaluated face-to-face by a licensed independent practitioner or trained RN within 1 hour after initiation of restraints or seclusion.

Cross-reference Tag A-0178

Due to the scope and severity of these deficiencies, the Condition of Participation at 42 CFR 482.13 Patient Rights was NOT MET.

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Based on record review, interview and review of hospital policy and procedure, the hospital failed to follow its policy and procedure for restraint use for 1 of 14 patient records reviewed (Patient #1).

Failure to follow hospital policy and procedure for restraint use places patients at risk for physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Review of the hospital policy titled, "Restraint and Seclusion," number 8541384, revised 09/20, showed that the patient has the right to be free from seclusion and /or restraints of any form that are not medically necessary and are not used as a means of coercion, discipline, convenience, or retaliation.

2. On 01/04/23 at 12:32 PM, the investigator reviewed the hospital video monitoring of the Emergency Department (ED) from 12/11/22 beginning at 10:00 PM, that showed the complaint subject patient (Patient #1) exiting a patient treatment room in a wheelchair, leaning to the side. A large piece of fabric was noted to be around the patient's chest and under their arms, tied behind the back of the wheelchair.

3. On 01/05/23 at 7:32 AM, during an interview with the investigator, an ED Technician, (Staff#10) stated that the patient (Patient #1) was non-verbal and lethargic, and kept leaning forward in the wheelchair. The wheelchair seatbelt was on. Staff #10 stated that they placed a sheet around the patient, under their arms and around the wheelchair to keep the patient upright and safe during transportation.

4. On 01/05/23 at 8:17 AM, during an interview with the investigator, an ED staff nurse (Staff #11) stated that they and an ED Technician got the patient (Patient #1) dressed and into the wheelchair with the seatbelt on, but it wasn't really working. The tech placed a sheet around the patient for patient safety.

5. On 01/04/23 at 12:32 PM, during the review of the hospital video tape, the ED Director (Staff #2) stated that use of a sheet was a restraint, and not approved by the hospital policies and procedures.

6. On 01/04/23 at 12:32 PM, during the review of the hospital video tape, the Director for Safety, Security, Emergency Preparedness, Patient Safety Officer (Staff #4) stated that use of a sheet was not included in the hospital restraint training for nurses or non-nurses.

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Based on interview and review of patient records, the facility failed to modify the patient's plan of care when placing patients in restraints for 5 of 8 records reviewed (Patients #9, #11, #12, #13, #14).

Failure to provide a plan of care placed patients at risk for neglect of meeting basic needs.

Findings included:

1. Review of the hospital policy titled, "Restraint and Seclusion," number 8541384, revised 09/20, showed that the registered nurse would initiate the restraint template in the plan of care addressing safety concerns and identify the use of the restraint and steps initiated to facilitate the removal of the restraint as soon as possible. Changes to care because of the restraint would be noted. Care planning would not be performed in the emergency department electronic medical record module.

2. Review of patient medical records showed that there was no care planning related to restraints in 6 of 8 medical records reviewed (Patients #7, #9, #11, #12, #13, #14).

3. The lack of care planning related to restraints in medical records were verified by the Quality Management Coordinator (Staff #9) at the time of the review. .
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Based on record review and review of hospital policy and procedures, hospital staff failed to ensure that a licensed provider wrote orders for restraint according to hospital policy guidelines for 2 of 8 patient records reviewed (Patients #11, #12).

Failure to ensure that a provider writes an appropriate order for seclusion and restraint puts patients at risk for psychological harm, loss of dignity, and personal freedom.

Findings included:

1. Review of the hospital policy titled, "Restraint and Seclusion," number 8541384, revised 09/20, showed that the licensed independent practitioner (LIP) orders restraints or seclusion in the medical record. The restraint order must be placed within 1 hour of restraint application.

2. Review of patient medical records showed that LIP orders for restraints were placed more than 24 hours after non-violent restraints were initiated for 2 of 8 records reviewed (Patients #11 and #12).

3. The findings of the above discrepancies in the medical records were verified by the Quality Management Coordinator (Staff #9).

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Based on interview, record review, and review of hospital policies and procedures, the hospital failed to ensure that patients were evaluated face-to-face by a licensed independent practitioner or trained RN within 1 hour after initiation of the restraints or seclusion, as demonstrated by 5 of 14 patients reviewed (Patients #7, #11, #12, #13, #14).

Failure to follow approved policies and procedures for restraint use risks physical and psychological harm, loss of dignity, and violation of patient rights.

Findings included:

1. Review of the hospital policy titled, "Restraint and Seclusion," number 8541384, revised 09/20, showed that the licensed independent practitioner (LIP) must conduct a documented face to face assessment within the first 24 hours of initiation of non-violent restraints.

2. On 01/04/23 between 2:15 PM and 3:15 PM, the investigator, the Intensive Care Unit Director (Staff #7), and the Quality Management Coordinator (Staff #9) reviewed the medical records for 14 patients (Patient #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14). The review showed that there was no face to face assessment in 5 of 14 records reviewed (Patients #7, #11, #12, #13, #14).

3. At the time of the review Staff #9 verified there was no face-to-face assessment documented for Patient #7, #11, #12, #13, and #14.

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Based on interview, document review, and review of quality documents, the hospital failed to use the quality data collected to take actions aimed at performance improvement, to evaluate the success of the action plans implemented, and monitor ongoing performance to ensure improvements are sustained.

Failure to implement, evaluate, and monitor projects and action plans based on results of data collection aimed at improving patient outcomes places patients at risk from harm due to substandard care.

Findings included:

1. Review of the hospital policy titled, "Quality and Safety Plan," number 11653446, revised 05/22, showed that Performance Improvement Teams exist to oversee the improvement process for the population or care processes with which they have been tasked by the Quality Council or Executive Council. These teams utilize rapid cycles of improvement to reach the goal of rapid implementation and transfer of knowledge throughout the organization. These teams work to identify suboptimal care and then develop sustainable improvements with the patient first in mind. Quality Improvement and patient safety are measured through the systematic collection of data and analysis of that data in relationship to accepted norms, anticipated goals, and industry standards.

2. Review of the hospital quality reporting schedule dated 2022 showed that restraints would be reported quarterly to the Quality Council. Review of the restraint audits for 2022 showed that data was gathered quarterly except that auditing for care planning related to restraints was blank. Audit results for physician/licensed independent practitioner order, and restraint order renewal every 24 hours for non-violent restraints were both documented at 65% compliance for quarter 4, 2022. For behavioral/violent restraints, there was no data for restraint orders renewed according to policy, provider orders were found to be 60% compliant for quarter 1, 89% compliant in quarter 2, 81% compliant in quarter 3, and 88% compliant in quarter 4, 2022. Continuous monitoring with documented safety checks every 15 minutes was 10% in quarter 1, 33% in quarter 2, 48% in quarter 3 and 25% in quarter 4, 2022.

3. Review of the hospital Quality Council meeting minutes for 2022 showed that there were no identified thresholds established for restraint monitoring indicators and there were no action plans for performance improvement identified.

4. On 01/05/23 at 10:25 AM, during an interview with the investigator, the Quality Management Coordinator, (Staff #9), stated that there was a Process Improvement Team established for restraints, as restraints were identified in the hospital's top 10 priorities for improvement, but when COVID-19 hit, hospital priorities changed, and the team had not been reassembled. Staff #9 stated that there is no threshold for compliance listed on the audit tool or reporting schedule, but the hospital uses 90% as their acceptable threshold. Staff #9 stated that the report used to pull the restraint data would not pull information about care plans, so that was not reported. There was no timeframe or estimated completion for fixing the report tool.


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