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Based on a review of 3 restraints, it was determined that the hospital restrained patient #7 without justification to do so, and used inappropriate criteria for release from restraints for patient #7 (P7) and patient #13 (P13).

Patient #7 was a 60+ adult male who presented to the emergency department with a gastrointestinal complaint. Upon presenting, it was determined that P7 was in a manic state and required a psychiatric evaluation. This was done and P7 was determined to require inpatient psychiatric care. While awaiting disposition, an RN note of 1240 stated, "Pt is very agitated and refuse to stay in the room. Security is called. MD is aware and meds ordered. Pt is also refusing to sit on the stretcher and threatening that he will get louder and not cooperate with care." A follow-up RN note of 1250 revealed, "Pt is back in bed and is medicated as per orders. Pt is still talkative but calmer."

Review of the record revealed that at 1248, P7 was placed into 4-point violent restraints, but was managed under a heading of non-violent restraints. Documentation further revealed that "No agitation" was necessary for release from restraint. This was a subjective discontinuation criterion, where the only objective behavioral criterion for release that should have been applied is the cessation of violent behavior.

P7 was taken out of the restraints 10 minutes later, at 1300. Following review of all documentation, it was determined that P7 demonstrated no imminently dangerous behavior that justified the use of four-point restraints. Further, the documentation indicated that P7 was restrained only because P7 was uncooperative with staying in the room and on the bed.

Patient #13 (P13) was a late adolescent who presented to the hospital in April 2019 with abdominal pain. P13 had a blood sugar condition and a long-standing psychiatric condition.

P13 was placed into restraints in multiple events of attempts to elope which terminated in aggressive behaviors. Orders were written in 2-hour increments with multiple inappropriate criterion for release including: "No agitation; Able to follow instructions; No angry outburst; No exhibition behaviors; and Awake, alert and oriented." Failure to comply with these subjective criterion were not sufficient justification for staff to continue to restrain P13. Failure to meet the other criterion listed, "No Aggression and No verbal threats of harm" were the only behaviors which justified continued restraint. It was unrealistic for staff to impose cognitive release criteria on P13-criteria P13 may not have been able to meet at any time.

In summary, one patient, P7 was restrained in four-point restraints because P7 could not follow staff direction due to P7's manic state, and P13 were restrained for longer than necessary after failing to meet arbitrary, subjective, and non-behaviorally based criteria for release.

Based on interviews and a review of the hospital Security Policy job description and training, it was determined that nursing staff in the emergency department did not receive manual restraint training thus rendering them unable to give clinical oversight to manual restraints used on patients by security personnel; and Security Police received no healthcare restraint training enabling safe restraint processes and clinical oversight in the therapeutic environment.

1) Interview with the Emergency Department (ED) Manager on August 20, 2019 at approximately 0930 revealed that ED nurses received training for the application of mechanical restraints, but not training for manual restraints. While ED Manager indicated that the intention was to start training in a type of manual healthcare restraint, in the interim, ED nurses were rendered unable to give clinical oversight in the event of a manual restraint by Security staff.

2) Review of the job description for contracted Security Police revealed in part, "Assists nursing and medical staff with the control of violent or disruptive patients..." This meant that the control of violent and disruptive patients would occasion the use of manual restraint.

Review of Special Police training revealed no evidence of hospital healthcare restraint training for manual restraints. This lack of training was confirmed with the hospital. Since Security Police used police training to conduct manual restraints, clinicians could not provide clinical oversight.

Based on a review of 3 restraints, it was determined that for patient #7 (P7) who was placed into 4-point violent restraints, an order for restraint was written as a non-violent restraint; and was written more than 1 hour after the restraint was initiated.

1) Patient #7 was a 60+ adult male who presented to the emergency department with a gastrointestinal complaint. Upon presenting, it was determined that P7 was in a manic state and required a psychiatric evaluation. This was done and P7 was determined to require inpatient psychiatric care. While awaiting disposition, a RN note of 1240 stated, "Pt is very agitated and refused to stay in the room. Security is called. MD is aware and meds ordered. Pt is also refusing to sit on the stretcher and threatening that he will get louder and not cooperate with care."

2) Review of the record identified that at 1248, P7 was placed into 4-point restraints which represents a violent restraint. No order was written until approximate 1.5 hours later at 1412. This order was labeled, "Non-Violent and Non-Self-Destructive" restraint for "Behavior" of "physically aggressive." The order documented "Type of restraint as: Bilateral Upp Extremities, Bilateral Low Extremities," which constituted a violent restraint.

In summary, the hospital applied a violent restraint to P7, increasing the risk for injury, but wrote a non-violent restraint order which did not require the level of clinical supervision and the close observation that P7 required. Further, the hospital failed to obtain a timely order for restraint per regulatory requirements.

See Tag A-0154. Just as P7 did not meet criteria for four-point restraints for violent behavior, P7 also did not meet criteria for non-violent restraints.

Based on a review of patient #13's record, it was determined that restraint documentation failed to meet the four Face to Face requirements.

Patient #13 (P13) with was a late adolescent who presented to the hospital in April 2019 with abdominal pain. P13 had a blood sugar condition and a long-standing psychiatric condition.

P13 was placed into restraints during multiple attempts to elope which terminated in aggressive behaviors. Orders were written in 2-hour increments. Some examples of face to face documentation are as follows:

The first restraint began with placement into 4-point restraints on day one at 0600. The first physician progress note was untimed and could have been done anytime between 0630 and 0827 when the next progress note was written. The progress note also failed to meet requirements for documentation of an assessment of P13's medical condition and whether the restraints could be removed.

At 1430, patient was taken out of restraints, but became violent again. The physician wrote, "patient screaming and combative, reordered restraints." This documentation addressed only the immediate situation of the face to face and not the other three required components.

Restraints were discontinued on or about 1854. However, P13 attempted to elope and then tried to bite security staff. P13 was restrained again. No documentation addressed P13 response to the restraint, the medical condition, or whether P13 needed to continue in restraints.

In summary, the hospital had no consistent way in which to document the requirements of the face to face, and so failed to meet those requirements.