HospitalInspections.org

.


Based on interview, observation, and record review the facility failed to ensure patients' rights were protected and promoted in accordance's to the Condition of Participation: CFR 482.13 Patient's Rights. Findings:

The facility failed to ensure an allegation of mistreatment was thoroughly investigated. Referenced at citation A-145.

The facility failed to ensure the use of mechanical restraints was conducted in a manner that was approved, safe and prevented injury. This failed practice resulted in actual injury to a patient. Referenced at citation A-167.

The facility failed to ensure a physician's order for the use of a mechanical restrain was obtained. Referenced at citation A-168.

The facility failed to ensure physician's orders for continued used of restraints were obtained. Referenced at citation A-171.

The facility failed to ensure a restraint was discontinued at the earliest possible time. Referenced at citation A-174.

The facility failed to ensure the observation and assessment were documented and/or completed by staff assigned to oversee care during restraint events as indicated by facility policy. Referenced at citation A-175.

The facility failed to ensure the consistent restraint training content was provided to employees of various roles in the facility. Referenced at A-199.
.

.


Based on record review, observation and interview the facility failed to ensure an allegation of mistreatment was thoroughly investigated for 1 patient (#3) out of 4 sampled patients who experienced restraint events. This failed practice placed all patients in the psychiatric emergency department at risk for receiving less than optimal care in an unsafe environment. Findings:

Patient #3:

Review of Patient #3's medical record from 9/23-24/19 revealed the Patient was brought into the psychiatric emergency department (Psych ED) with suicidal ideation and gestures. Further review revealed the Patient had a history of polysubstance abuse, alcoholism, domestic violence, post-traumatic stress disorder (PTSD), neuropathy, anxiety, panic disorder and depression.

Additional review of the medical record revealed the patient was exhibiting unsafe behaviors that resulted in the Patient being placed in 4-point restraints (method of restraining each limb) on 9/10/19.

Restraint Event 9/10/19:

Observation on 9/23/19 at 1:44 pm, of Security Staff #1 body camera footage, revealed Patient #3 was brought in the Emergency Room by APD (Anchorage Police Department) around 8:19 pm on 9/10/19. The Patient was uncooperative and yelling that he/she had PTSD. The Patient was escorted from triage to a patient room by security staff. The Patient was then placed in four-point violent restraints at 8:29 pm. Further review of the camera footage dated 9/10/19 at 8:54 pm, revealed Patient Care Technician (PCT) #1 released the right wrist restraint while the Security Staff #2 was still holding the patient's right wrist with two hands. As the right wrist restraint was released, the Patient's right arm was brought upward towards the head part of the bed while Security Officer #2 was still holding the right wrist and a popping sound was heard through the video audio. The Patient immediately began yelling "I heard a crack."

During an interview on 9/23/19 at 2:30 pm, with Security Officer #1, stated when the right restraint was removed, he/she heard a pop-like noise when the Patient's arm went upward. Security Officer #1 stated the pop-like noise was loud enough that all staff in the room could have heard it. He/she added that the incident was written in his/her report. When asked to show his/her encounter within the written report, Security Staff #1 reviewed security incident report # 19-712 and stated he/she was not able to locate his/her encounter in the document.

Observation on 9/24/19 at 9:00 am, of camera footage from the ceiling mounted camera of the 9/10/19 restraint event with Patient #3, revealed at 8:54 pm PCT #1 released the right wrist restraint while Security Staff #2 was still holding the patient right wrist with two hands. As the right wrist restraint was released, Security Staff #2 lowered his/her body in preparation for the transition of the Patients right arm. When the Patient's right arm was released and brought upward towards the head part of the bed by Security Staff #2, Mental Health Specialist (MHS) #1 used both hands to grasp above Security Staff #2's hands on the mid-section of the Patient's forearm. The instant that MHS #1 grasped the arm, both Security Staff #2 and MHS #1 appeared to lean back to counter act any opposing force caused by the Patient. The Patient immediately began to yell out in distress stating he/she heard a crack.

Observation on 9/24/19 at 9:10 am, of Security Staff #3 body camera footage of the 9/10/19 restraint event with Patient #3, revealed that when the Patient's wrist restraint was released, the Patient's arm was moved upward while Security Staff #2 was holding the Patient's right wrist with two hands. During the transition of the Patient's right arm to the upper part of the bed, MHS #1, who was standing behind the head part of the bed, grasped the Patient's arm above the hands of Security Staff #2 on the mid-sections of the Patient's right forearm. Immediately after MHS #1 grasped the Patient's right forearm both Security Staff #2 and MHS #1 leaned back and an audible popping sound was heard.

During an additional interview on 9/24/19 at 9:30 am, the Security Manager stated security staff should have handled the Patient's right arm on his/her own. The Security Manager further stated that Psych ED staff have been instructed to allow security to lead the situation when they are actively using restraint skills. In addition, the Security Manger stated that Security Staff #2 was capable of handling the Patient's limb on his/her own.

Review of the facility provided training document "BE SAFE AT WORK: De-escalations and Violence Prevention," undated, revealed "When Security is Needed ...All staff ...should stay out of the way until security has controlled and retrained the patient ...ensure appropriate medical interventions and treatments."

Record review of a nursing note, dated 9/10/19 at 9:10 pm, revealed " ...security notified and on the unit to assist with repositioning the restraints, [Patient's right] arm was in low position, [Patient's right] arm moved into a higher position. [Patient] begins to yell, and is tearful. [Registered Nurse] into speak with the [Patient], [Patient] stating that 'I heard a crack.' [Patient's] restraints checked, hand cool to touch, [Patient] states [his/her] fingers are numb."

Record review of the Patient's right wrist x-ray narrative, dated 9/10/19 revealed the Radiologist stated the patient's bones were osteopenic (reduction in bone mass). The report stated the Patient had an oblique fracture (characterized by an angular break) with displacement (movement from original location) to the right ulna (bone in the forearm, opposite side of thumb).

During an interview on 9/24/19 at 8:45 am, the Radiologist stated that the Patient sustained an oblique fracture to his/her ulna. The Radiologist further stated the Patient's fractures was unusual in the fact that a fracture of the ulna normally had an associated fractured to the radius (adjacent bone to the ulna located on the forearm; on the thumb side). In addition, the Radiologist stated that being a solitary ulna fracture would have indicated a localized area of force to the area of the fracture. When asked about the health of the Patient's bones, the Radiologist stated that the x-ray indicated the Patient was osetopenic which would increase his/her risk of fractures. When asked what the reported etiology of the fracture was, the Radiologist stated according to the x-ray order it was stated as suicidal gesture.

Allegation of Abuse/Neglect/Mistreatment Investigation:

Review of the facility's policy "Complaint Management." Revision date 5/2019, revealed " ...investigating the complaints or grievances and documenting that investigation in the [Facility's Investigation Documentation Software] ...All complaints/grievances should be reported in the Datix System."

Review of the facility's investigative documentation notes revealed Pysch Emergency Room (ED) Assistant Nurse Manager (PEDANM) spoke to Patient #3 on 9/11/19 at 1:40 pm. Further review revealed PEDANM asked Patient #3 " ...were the caregivers attempting to put [him/her] back into restraints." The Patient responded " ...yes and that the [type of fracture] occurred because they were using excessive force." Further review revealed Grievance/Complaints Service Excellence Program Manager documented "Patient incurred injury while being restrained."

During an interview on 9/24/19 at 9:30 am, the Security Manager stated he/she reviewed the footage and stated he/she determined that the security staff followed protocol. The Security Manager stated he/she was unaware that MHS #1 had grasped the arm in conjunction with Security Staff #2. The Security Manger further stated he/she was reviewing the practices of security staff as opposed to healthcare staff.

During an interview on 9/24/19 at 9:45 am, with Risk Patient Safety Specialist (RPSS), when asked about the facility's response to the fracture event related to restraint use, he/she explained that the event was reviewed the following morning by evaluating unusual occurrence reports (UOR), camera footage, talked to patient and read the Patient's medical record. When asked to explain each step of the review, the RPSS stated he/she watched one security staff's body camera footage that was filmed from the Patient's left side. When asked if other security staffs' body cameras or ceiling camera footage was reviewed the RPSS stated no and that he/she was unaware that the room had a ceiling camera. The RPSS further stated based off his/her review, he/she felt the care provided was acceptable and correct methods were utilized.

During the same interview when asked what staff were observed to be handling the Patient's right arm, the RPSS stated a female security staff was handling the Patient's right arm during the transition from the lower position to the upper position. When asked if he/she was aware that MHS #1 grasped the Patient's right forearm during the restraint transition, the RPSS state he/she was unaware that two staff (Security Staff #2 and MHS #1) had grasped the Patient's right arm and as a result was not considered in the evaluation of the event nor placed in the final report.

During an interview on 9/24/19 at 11:16 am, with Grievance/Complaints Service Excellence Program Manager, he/she stated that his/her determination was based on RPSS final report findings.

Review of the facility's policy "Restraint Management," last revised 2/2017, revealed "The use of restraints is a significant intervention. It has the potential to produce serious psychological and physiological consequences, especially for vulnerable patient populations, such as emergency ...and cognitively or physically limited patients."

Review of the facility's policy "Patient Rights and Responsibilities," dated 5/2018, revealed "As a patient at Providence Alaska Medical Center you have the right to ...freedom from mental, physical, sexual and verbal abuse, neglect and exploitation ...Rights & Responsibilities for Mental Health Patients under Alaska State Law ...Your physical safety ...will be taken into account."

.

.

Based on record review, observation and interview the facility failed to ensure the use of a mechanical restraints for 1 patient (#3) out of 4 sampled patients, who experienced restraints, was conducted in a manner that was approved, safe and prevented injury. This failed practice resulted in the Patient sustaining a fracture to his/her arm. Findings:

Review of Patient #3's medical record from 9/23-24/19 revealed the Patient was brought into the psychiatric emergency department (Psych ED) with suicidal ideation and gestures. Further review revealed the Patient had a history of polysubstance abuse, alcoholism, domestic violence, post-traumatic stress disorder (PTSD), neuropathy, anxiety, panic disorder and depression.

Additional review of the medical record revealed the patient was exhibit unsafe behaviors that resulted in the Patient being placed in 4-point restraints (method of restraining each limb) on 9/10/19.

Observation on 9/23/19 at 1:44 pm of Security Staff #1 body camera footage, revealed Patient #3 was brought in the Emergency Room by APD (Anchorage Police Department) around 8:19 pm on 9/10/19. The Patient was uncooperative and yelling that he/she had PTSD. The Patient was escorted from triage to a patient room by security staff. The Patient was then placed in four-point violent restraints at 8:29 pm. Further review of the camera footage dated 9/10/19 at 8:54 pm, revealed Patient Care Technician (PCT) #1 released the right wrist restraint while the Security Staff #2 was still holding the patient right wrist with two hands. As the right wrist restraint was released, the Patient's right arm was brought upward towards the head part of the bed while Security Officer #2 was still holding the right wrist and a popping sound was heard through the video audio. The Patient immediately began yelling "I heard a crack."

During an interview on 9/23/19 at 2:30 pm, with Security Officer #1, stated when the right restraint was removed, he/she heard a pop-like noise when the Patient's arm went upward. Security Officer #1 stated the pop-like noise was loud enough that all staff in the room could have heard it. He/she added that the incident was written in his/her report. When asked to show his/her encounter within the written report, Security Staff #1 reviewed security incident report # 19-712 and stated he/she was not able to locate his/her encounter in the document.

Observation on 9/24/19 at 9:00 am, of camera footage from the ceiling mounted camera of the 9/10/19 restraint event with Patient #3, at 8:54 pm revealed PCT #1 released the right wrist restraint while the Security Staff #2 was still holding the patient right wrist with two hands. As the right wrist restraint was released, Security Staff #2 lowered his/her body in preparation for the transition of the Patients right arm. When the Patient's right arm was released and brought upward towards the head part of the bed by Security Staff #2, Mental Health Specialist (MHS) #1 used both hands to grasp above Security Staff #2's hands on the mid-section of the Patient's forearm. The instant that MHS #1 grasped the arm, both Security Staff #2 and MHS #1 appeared to lean back to counter act any opposing force caused by the Patient. The Patient immediately began to yell out in distress stating he/she heard a crack.

Observation on 9/24/19 at 9:10 am, of Security Staff #3 body camera footage of the 9/10/19 restraint event with Patient #3, revealed when the Patient's wrist restraint was released, the Patient's right arm was moved upward while Security Staff #2 was holding the Patient's right wrist with two hands. During the transition of the Patient's right arm to the upper part of the bed, MHS #1, who was standing behind the head part of the bed, grasped Patient #3's arm above the hands of Security Staff #2 on the mid-sections of the Patient's right forearm. Immediately after MHS #1 grasped the Patient's right forearm both Security Staff #2 and MHS #1 leaned back and an audible popping sound was heard.

During an additional interview on 9/24/19 at 9:30 am the Security Manager stated security staff should have handled the Patient's right arm on his/her own. The Security Manager further stated that Psych ED staff have been instructed to allow security to lead the situation when they are actively using restraint skills. In addition, the Security Manger stated that Security Staff #2 was capable of handling the Patient's limb on his/her own.

Review of the facility provided training document "BE SAFE AT WORK: De-escalations and Violence Prevention," undated, revealed "When Security is Needed ...All staff ...should stay out of the way until security has controlled and retrained the patient ...ensure appropriate medical interventions and treatments."

Record review of a nursing note, dated 9/10/19 at 9:10 pm, revealed " ...security notified and on the unit to assist with repositioning the restraints, [Patient's right] arm was in low position, [Patient's right] arm moved into a higher position. [Patient] begins to yell, and is tearful. [Registered Nurse] into speak with the [Patient], [Patient] stating that 'I heard a crack.' [Patient's restraints checked, hand cool to touch, [Patient] states [his/her] fingers are numb."

Record review of the Patient's right wrist x-ray narrative, dated 9/10/19 revealed the Radiologist stated the patient's bones were osteopenic (reduction in bone mass). The report stated the Patient had an oblique fracture (characterized by an angular break) with displacement (movement from original location) to the right ulna (bone in the forearm, opposite side of thumb).

During an interview on 9/24/19 at 8:45 am, the Radiologist stated that the Patient sustained an oblique fracture to his/her ulna. The Radiologist further stated the Patient's fractures was unusual in the fact that a fracture of the ulna normally had an associated fractured to the radius (adjacent bone to the ulna located on the forearm; on the thumb side). In addition, the Radiologist stated that being a solitary ulna fracture would have indicated a localized area of force to the area of the fracture. When asked about the health of the Patient's bones, the Radiologist stated that the x-ray indicated the Patient was osetopenic which would increase his/her risk of fractures. When asked what the reported etiology of the fracture was, the Radiologist stated according to the x-ray order it was stated as suicidal gesture.

Review of the facility's policy "Restraint Management," last revised 2/2017, revealed "The use of restraints is a significant intervention. It has the potential to produce serious psychological and physiological consequences, especially for vulnerable patient populations, such as emergency ...and cognitively or physically limited patients."

.

.

Based on record review and interview the facility failed to ensure a physician's order for a mechanical restraint was obtained for 1 patient (#6) out of 4 sampled patients who experienced restraint events. This failed practice placed the patients at risk for unnecessary physical restraint without a physician order and further psychological instability. Findings:

Record review from 9/20-24/19 revealed Patient #6 was admitted to the facility with a diagnosis that included acute psychosis (A mental disorder characterized by disconnection from reality which results in strange behavior often accompanied by perception of stimuli [voices, images, sensations] and other hallucinations).

Review of "Restraints All" summary, dated 9/16/19 at 6:30 pm, revealed Patient #6 was initially placed in 4 point mechanical restraint (both wrists and ankles restrained to the bed) and remained in restraints until 9/17/19 at 6:19 am.

Review of the physician's orders revealed no orders documented for the use of mechanical restraints for the time period between 9/16/19 at 6:30 pm through 10:24 pm (total of 3 hours and 54 minutes).

During an interview on 9/23/19 at 4:00 pm, Mental Health Clinician (MHC) #1 reviewed Patient #6's electronic medical record (EHR) and was unable to locate the physician's order for the restraint on 9/16/19 between 6:30 pm and 10:24 pm. The MHC further stated there should have been an initial physician's order in the EHR.

Review of the facility's policy "Restraint Management," revised 2/2017, revealed "Physical Restraint (Requires a Practitioner's Order) ...Attachment B Restraint Guideline Summary ...Physician order ...Obtained at time restraints are applied or immediately thereafter..."
.

.


Based on record review, interview and policy review, the facility failed to ensure physician's orders for continued used of restraints were obtained for 1 patient (#6) out of 4 sampled patients who experienced a restraint event. This failed practice placed the patient at risk for unnecessary continuation of physical restraints without a physician order. Findings:

Physician's orders:

Patient # 6 - 9/15/19:

Record review from 9/20-24/19 revealed Patient #6 was admitted to the facility with a diagnosis that included acute psychosis (A mental disorder characterized by disconnection from reality which results in strange behavior often accompanied by perception of stimuli [voices, images, sensations] and other hallucinations).

Review of "Restraints All" summary, dated 9/15/19 at 5:40 am, revealed Patient # 6 was placed in 4 point restraints (both wrists and ankles restrained to the bed) and a physician's order was obtained at 5:52 am.

Review of a physician's order "Restraint adult [with] violent behavior," dated 9/15/19 at 12:52 pm, revealed the Patient continued to require the restraints for "physical safety of themselves or others ...Orders must be renewed every 4 hours." The restraints were removed at 5:23 pm.

Further review revealed no physician orders for the continued use of restraints from 4:52 pm until the restraints discontinued at 5:23 pm.

During an interview on 9/23/19 at 4:00pm, Mental Health Clinician (MHC) #1 reviewed Patient #6's electronic health record (EHR) and was unable to locate the physician's order for the continued use of restraints on 9/15/19 between 4:52 pm until 5:23 pm. The MHC further stated that there should have been a physician's order in the EHR covering use of restraint during that time period.

Patient # 6 - 9/16/19:

Review of "Restraints All" summary, dated 9/16/19 at 6:50 am, revealed Patient #6 was placed in 4 point restraints and a physician's order was obtained at 6:53 am.

Review of a physician's order "Restraint adult [with] violent behavior," dated 9/16/19 at 6:53 am, revealed the Patient required the restraints for "physical safety of themselves or others ...Orders must be renewed every 4 hours."

Review of "Restraints All" summary, dated 9/16/19 from 10:53 am to 11:23 am, revealed Patient #6 continued to have been in 4 point restraints.

Review of a physician's order "Restraint adult w/ [with] violent behavior," dated 9/16/19 at 11:23 am, revealed the Patient required restraints for "physical safety of themselves or others ...Orders must be renewed every 4 hours."

Further review revealed no physician orders for the continued use of restraints for the timeframe between 10:53 am to 11:23 am.

During an interview on 9/23/19 at 4:00 pm, MHC #1 reviewed Patient #6's EHR and was unable to locate the physician's order for the continued use of restraints on 9/16/19 between 10:53 am to 11:23 am. The MHC further stated there should have been a physician's order in the EHR.

Patient # 6 - 9/17/19 #1:

Review of "Restraints All" summary, dated 9/16/19 at 6:30 pm, revealed Patient #6 was placed in 4 point restraints and remained in restraints until 9/17/19 at 6:19 am.

Review of the physician's orders revealed no orders documented for the restraints for the time period between 9/16/19 at 6:30 pm through 10:24 pm. Further review revealed no physician's orders for the time frame on 9/17/19 from 6:10 am through 6:19 am.

During an interview on 9/23/19 at 4:00 pm, MHC #1 reviewed Patient 6's EHR and was unable to locate the physician's order for the restraint on 9/16/19 between 6:30 pm and 10:24 pm. The MHC further stated there should have been a physician's order in the EHR.

Patient # 6 - 9/17/19 #2:

Review of "Restraints All" summary, dated 9/17/19 from 4:15 pm through 5:07 pm revealed Patient # P was in 2 point restraints (both wrists restrained to bed). The restraints were discontinued at 5:07 pm.

Review of a physician's order "Restraint adult [with] violent behavior," dated 9/17/19 at 12:55 pm, revealed the Patient required the restraints for "physical safety of themselves or others ...Orders must be renewed every 4 hours." Further review revealed no physician orders for the continued use of restraints on 9/17/19 for the timeframe between 4:55 pm through 5:07 pm.

During an interview on 9/23/19 at 4:00pm, MHC #1 reviewed Patient #6's EHR and was unable to locate the physician's order for the continued use of restraints on 9/17/19 between 4:55 pm and 5:07 pm. The MHC further stated there should have been a physician's order in the EHR.

During an interview on 9/23/19 at 2:30 pm, LN #2 reviewed the facility's policy and stated a physician's order for restraints needed to be renewed every 4 hours if the patient continued to require the restraints for violent behaviors.

Review of the facility's policy "Restraint Management," revised 2/2017, under attachment B "Restraint Guideline Summary" for violent or destructive behavior revealed "Time limit for restraint order ...4 hours [for] adults."
.

.


Based on record review, interview and policy review, the facility failed to ensure a restraint was discontinued at the earliest possible time, for 1 patient (#7) out of 4 sampled patients who experienced restraint. Specifically, the patient remained in restraints while asleep. This failed practice placed the patient at risk for excessive restraint time and potential for psychosocial instability. Findings:

Record review on 9/20-24/19 revealed Patient #7 was admitted to the facility with a chief complaint of altered mental status.

Review of "Restraints All" summary, dated 9/19-20/19, revealed Patient #7 was in 4 point mechanical restraints (both wrists and ankles restrained to the bed) from 9/19/19 at 8:20 pm until 9/20/19 at 2:00 am.

Further review of the "Restraints All" summary revealed a subsection titled "Q2 [every 2 hour] Monitoring" on 9/19/19 at 10:40 pm, "Patient [was] asleep."

Further review of the "Restraints All" summary revealed a subsection titled "Q15 [every 15 minute] Monitoring" from 9/19 at 11:45 pm until 9/20/19 at 12:15 am. The documentation revealed "Current Behavioral Response" was agitated and beginning to rest quietly. Further review revealed:

- 12:30 am the response was documented at "agitated and calming down."

- 12:45 am to 1:00 am, the response was documented as "beginning to rest quietly."

- 1:15 am to 1:30 am, the response was documented as sleeping and sedated.

The restraints were not discontinued until 2:00 am.

Further review of the "Restraints All" summary revealed a subsection titled "Criteria for Release Met" and "Release Criteria Explained" revealed no documentation from 9/19/19 at 8:46 pm until release on 9/20/19 at 2:00 am.

Review of a Nurse's Note, dated 9/19/19 at 11:34 pm, revealed "[Patient] sleeping at this time. 1:1 [trained observer] remains at bedside, [Patient] does not meet criteria for release from restraints."

Review of a physician's order "Restraint adult [with] violent behavior," dated 9/20/19 at 1:18 am, revealed "Reason for restraint ...danger to self ...Release when ...originating behavior no longer evident ... less restrictive measures effective."

During an interview on 9/24/19 at 11:25 am, Psych Emergency Department Assistant Nurse Manager (PEDANM) stated he/she would not keep a patient in restraints if the patient was sleeping. The PEDANM further stated if a Licensed Nurse (LN) documented that a patient was asleep, he/she would question why the patient was not released from the restraint.

Review of the facility's policy "Restraint Management," revised 2/17, revealed "The use of restraints is a significant intervention. It has the potential to produce serious psychological and physiological consequences, especially for vulnerable patient populations, such as emergency ...cognitively or physically limited patients." Further review under Attachment B- "Restraint Guideline Summary" revealed "Documentation: required q15 min ... if criteria for release has been met ....Restraint use must end as soon as possible regardless of the length of time identified in the order. May be discontinued by RN when criteria for release as defined in order has been met."

Review of the facility's policy "Patient Rights and Responsibilities," revised 5/18, under attachment A- "Rights and Responsibilities of Patients ..." revealed "As a patient ...you have the right to: ...Be free from restraints other than those medically indicated for your safety."

.

.
Based on record review and interview the facility failed to ensure the observation and assessment of 2 patients (#s 6 and 7) out of 4 sampled patients, who experienced restraint events, were documented and/or completed by staff assigned to oversee care during restraints as indicated by facility policy. This failed practice placed the patients at risk for less than optimal care, as well as, negative physiological and psychological outcomes. Findings:

Patient #6

Record review from 9/20-24/19 revealed Patient #6 was admitted to the facility with a diagnosis that included acute psychosis (A mental disorder characterized by disconnection from reality which results in strange behavior often accompanied by perception of stimuli [voices, images, sensations] and other hallucinations).

Review of a physician's order "Restraint adult [with] violent behavior," dated 9/15/19 at 5:52 am, revealed a restraint order for Patient #6 due to "physical safety of themselves or others ...RN or Trained Observer to document patient interventions/observations/condition per facility policy."

Review of "Restraints All" summary, dated 9/15/19 at 5:40 am, revealed Patient #6 was placed in 4 point restraints. Further review revealed no documentation from 6:01 am to 6:59 am under "Q15 [every 15 minute] Monitoring" of current mental status, current behavioral response, comfort measures, continuous observation, restraint right and left wrist, restraint right and left ankle.

During an interview on 9/23/19 at 2:35 pm, Licensed Nurse (LN) #3 stated assessments of patients who have been restrained for violent behaviors should have all of their restrained extremities monitored and documented every 15 minutes.

During an interview on 9/24/19 at 9:45 am, Quality Assurance (QA) Director reviewed "Restraint All" Summary documentation for Patient #6's restraint event on 9/15/19 between 6:01 am to 6:59 am and stated the documentation and monitoring of current mental status, current behavioral response, comfort measures, continuous observation, restraint right and left wrist, restraint right and left ankle were missing. The QA director then reviewed the nursing documentation in Patient #6's medical record pertaining to the restraint event on 9/15/19 from 6:01 am to 6:59 am, and stated no bedside assessment had been documented.

Patient #7:

Record review on 9/20-24/19 revealed Patient #7 was admitted to the facility with a chief complaint of altered mental status.

Review of "Restraints All" summary, dated 9/19-20/19, revealed Patient # 7 was in 4 point restraints for violent behavior from 9/19/19 at 8:20 pm until 9/20/19 at 2:00 am.

Further review of the "Restraints All" summary subsection titled "Q2 [every 2 hour] Monitoring" on 9/19/19 at 10:40 pm, revealed documentation completed for the assessment of Peripheral Neurovascular (assessment for adequate nerve function and blood circulation), Skin, and Range of Motion/Repositioning. Further review revealed no further documentation of monitoring these parameters were done for 3 hours and 20 minutes, at which time the restraint was released.

Further review of the "Restraints All" summary subsection titled "Criteria for Release Met" revealed no documentation from 9/19/19 at 8:46 pm to 9/19/19 at 2:00 am, at which time the restraint was released.

Review of the facility's policy "Restraint Management," revised 2/2017, under attachment B "Restraint Guideline Summary" for violent or destructive behavior revealed "Documentation: required q15 min, RN or observer ...Mental status, behavioral response, comfort measures, peripheral neurovascular, skin, CVO [continuous visual observation], type of restraint and location, behavior/release assessment and if criteria for release has been met." Further review revealed "Documentation: required q2h [every 2 hours], RN ...Range of motion/repositioning."
.

.

Based on record review, observation and interview the facility failed to ensure the consistent restraint training content was provided to employees of various roles in the facility. This failed practice resulted in 1 patient (#3) out of 4 sampled patients, who experienced restraint events, receiving a fracture to his/her arm during a restraint event. Findings:

Review of Patient #3's medical record from 9/23-24/19 revealed the Patient was brought into the psychiatric emergency department (Psych ED) with suicidal ideation and gestures. Further review revealed the Patient had a history of polysubstance abuse, alcoholism, domestic violence, post-traumatic stress disorder (PTSD), neuropathy, anxiety, panic disorder and depression.

Additional review of the medical record revealed the patient was exhibit unsafe behaviors that resulted in the Patient being placed in 4-point restraints (method of restraining each limb) on 9/10/19.

Observations on 9/23-24/19 of three different camera views of the restraint event on 9/10/19 with Patient #3 revealed staff were repositioning the Patient's right arm from being restrained at waist level to above the head. Specifically, Patient Care Technician #1 released the right wrist restraint while the Security Staff #2 was still holding the patient right wrist with two hands. As the right wrist restraint was released, Security Staff #2 lowered his/her body in preparation for the transition of the Patients right arm. When the Patient's right arm was released and brought upward towards the head part of the bed by Security Staff #2, Mental Health Specialist (MHS) #1 used both hands to grasp above Security Staff #2's hands on the mid-section of the Patient's forearm. The instant that MHS #1 grasped the arm, both Security Staff #2 and MHS #1 appeared to lean back to counter act any opposing force caused by the Patient. The Patient immediately began to yell out in distress stating he/she heard a crack.

During an interview on 9/24/19 at 8:45 am, the Radiologist stated that the Patient sustained an oblique fracture to his/her ulna. The Radiologist further stated the Patient's fractures was unusual in the fact that a fracture of the ulna normally had an associated fractured to the radius (adjacent bone to the ulna located on the forearm; on the thumb side). In addition, the Radiologist stated that being a solitary ulna fracture would have indicated a localized area of force to the area of the fracture. When asked about the health of the Patient's bones, the Radiologist stated that the x-ray indicated the Patient was osetopenic which would increase his/her risk of fractures. When asked what the reported etiology of the fracture was, the Radiologist stated according to the x-ray order it was stated as suicidal gesture.

During an interview on 9/24/19 at 9:30 am, during camera reviews, the Security Manager stated Security Staff #2 should have handled the Patient's right arm on his/her own. The Security Manager further stated that Psych ED staff have been instructed to allow security to lead the situation when they are actively using restraint skills. In addition, the Security Manger stated that Security Staff #2 was capable of handling the Patient's limb on his/her own.

Review of the facility provided training document "BE SAFE AT WORK: De-escalations and Violence Prevention," undated, revealed "When Security is Needed ...All staff ...should stay out of the way until security has controlled and retrained the patient ...ensure appropriate medical interventions and treatments."

Review of the facility provided training document "2019 Housewide Skills Lab Tip Sheet for Trainers Violent Restraints - Adult," dated 2019, revealed "Violent Restraint Script for Skills Lab Do not teach to position patient one arm up, arm down, this is dangerous and can result in rotator cuff tear. Position patients supine [laying on his/her back] with arms down and joints in neutral position."

During an interview on 9/24/19 at 11:22 pm, Mental Health Clinician (MHC) #1 stated the Housewide Skills Lab Tip Sheet for Trainers sheet content was discussed collaboratively with a peer in April/May of 2019 and changes were to have been made regarding the use of placing one arm above the patient's head during restraints. When presented with current "2019 Housewide Skills Lab Tip Sheet for Trainers Violent Restraints - Adult," the MHC stated he/she didn't know that was still being taught in the skills lab. The MHC #1 further stated that an evaluation of the training materials and practical implementations needed to be reviewed and consistent.

During an interview on 9/24/19 at 11:25 am, with Pysch Emergency Room (ED) Assistant Nurse Manager (PEDANM) when asked about the training of ED Psych nurses, he/she stated that they do not do the 4 hour "BE SAFE AT WORK: De-escalation and Violence Prevention" course for de-escalation. The PEDANM stated Psych ED staff attend the Security Department's 1 ½ hour training and housewide skills lab. There is a de-escalation course with Security Staff #4 which included how to assist security staff during events. The PANM further stated clinical staff were allowed to assist security during a restraint episode.

Review of the facility's policy "Restraint Management," last revised 2/2017, revealed "The use of restraints is a significant intervention. It has the potential to produce serious psychological and physiological consequences, especially for vulnerable patient populations, such as emergency ...and cognitively or physically limited patients."

.