HospitalInspections.org

Based on review of hospital policy and procedures, medical record review and staff interviews, the hospital staff failed to use least restrictive interventions for 2 of 5 patients (Patients #4, #7).

The findings include:

Review of hospital policy, "No. CQ-4.004...Title: RESTRAINT AND SECLUSION...Review Dates...7/14" revealed, "...II. PURPOSE: The purpose of this policy is to define the Hospital's approach to the application of restraint and seclusion for patients in a way that protects the patient's health and safety, and preserves his or her dignity, rights and well-being. III. DEFINITIONS: A. "Restraint" means any method, physical or chemical, or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely. If the effect of using an object fits the definition of restraint for a specific patient at a specific time, then for that patient at that time, the device is a restraint. The definition renders unnecessary the otherwise impossible task of naming each device and practices that can inhibit a patients' movement...IV. POLICY It is the policy of this organization to limit the use of restraint and seclusion to those situations where it is necessary to ensure the immediate physical safety of the patient, staff members, or others with appropriate and adequate clinical justification and to facilitate the discontinuation of restraint or seclusion as soon as possible based on an individualized patient assessment and re-evaluation. V. PROCEDURE A. Methodology...4...make the patient aware of the rationale of the intervention...6. Once the patient meets the criteria for release, the restraint is discontinued. The decision to discontinue the intervention must include a determination that the patient's behavior is no longer a threat to himself/herself. 7. When a restraint is implemented, the patient's plan of care must be modified to reflect this change....e. discontinuation of restraint at earliest possible time. · Decision based on the determination that the medical need for restraint is no longer present or that the patient's needs can be met with less restrictive methods...Assessment of patient's condition to determine if the current restraint should be continued or if less restrictive methods could be used or restraints could be discontinued...DEFINITIONS: Physical Restraint Holding the patient means physically holding a patient in a manner that restricts his/her movement (this would include therapeutic holds) constitutes restraint for that patient. Holding a patient can be just as restrictive and potentially dangerous as restraining methods using devices. Physically holding a patient during forced psychotropic (or other) medication procedure is considered physical restraint. Chemical Restraint Is the appropriate use of a sedating psychotropic drug to manage or control behavior. A medication used to manage the patient's behavior or restrict the patient's freedom of movement that is not considered a standard treatment or dosage for the patient's condition is a chemical restraint. Medication should not be used at any time as a restraint..."

Review of hospital policy, "No. 14-1G-199...Title: SEDATION...Revised Date...07/14" revealed, "1. PURPOSE: To provide a guideline for safe and effective utilization of medications in the Intensive Care Unit (ICU) for continuous sedation in mechanically ventilated patients. II. POLICY: Sedative medications may be used for continuous sedation and control of stress responses in intubated, mechanically ventilated adult patients in the ICU. Some cases may require use of narcotic analgesia (the inability to feel pain) in addition to sedation for comfort. III. PROCEDURE A. Obtain doctor's order for sedation with degree of sedation desired specified using Richmond Agitation Sedation Score (RASS) (a medical scale used to measure agitation or sedation level of a patient), unless otherwise specified in orders...Richmond Agitation-Sedation Score (RASS)...+4 Combative (Combative, Violent, Immediate Danger to staff/self)...+3 Very Agitated (Pulls or removes tubes/catheters, Aggressive)...+2 Agitated (Frequent non-purposeful movements, fights ventilator)...+1 Restless (Anxious, apprehensive, but not aggressive or vigorous) ...0 Alert/Calm (Alert and Calm)...-1 Drowsy (Not fully alert, but has sustained awakening (able to maintain eye contact > (greater than) 10 seconds Opens eyes to voice and contact)...-2 Light Sedation (Drowsy awakens only briefly (Able to maintain eye contact < (less than) 10 seconds to voice or physical stimulation)...-3 Moderate Sedation (Movement or eye opening (but no eye contact) to voice...-4 Deep Sedation (No response to physical/painful stimuli)...-5 Unarousable (No response to voice or physical/painful stimuli). "

1. Closed medical record review of Patient #4 revealed physician documentation from 9/20/2014 at 12:12, "...History & Physical DATE OF ADMISSION: 09/20/2014 PRESENTING COMPLAINT: Agitation with subsequent cardiac arrest. HISTORY OF PRESENT ILLNESS: A 38-year-old male with history of bipolar disorder and hypertension, who was brought in to the ED yesterday for change in mental status with agitation and suicidal threats. Unfortunately, patient was already intubated during my encounter, was able to get any information from him...REVIEW OF SYSTEMS: Unable to adequately review due to patient's sedation on the vent (ventilator (machine used to provide breathing support for patient) ; however, major complaint has been having suicidal threats and agitation. ER COURSE AND MANAGEMENT: In addition to mentioned above after patient was intubated, he was placed on propofol (a drug used to help a patient relax before and during medical/surgical procedures), which was subsequently weaned down due to hypotension (low blood pressure). He required 2 doses of 2 mg (milligrams (unit of measurement) of Ativan (a drug used to treat anxiety disorders) for sedation in addition to paralytic and in addition to his restraints. Currently comfortable on vent...PHYSICAL EXAMINATION ...GENERAL: Patient is sedated and looks comfortable on the vent, noted a 3-cm (centimeter (unit of measurement)) laceration over the right occipital region (around the eye) with 3 stitches in place...ASSESSMENT AND PLAN: 1. Acute respiratory failure with cardiac arrest. Unsure of sitology of his sudden cardiac arrest and respiratory failure. There was documentation of 20 mg of Geodon given while patient was restrained on the floor by the cops which can cause respiratory depression... "Patient #4 was transferred to the Intensive Care Unit where he remained in restraints until he was transferred to an outside facility on 10/15/2015". Review of restraint documentation revealed that the named patient was in either violent or non-violent restraints from 09/20/2014 beginning at 08:40 until 10/15/2014 at 1330 at which time the patient was transferred from the named facility. Review of the "RESTRAINT FLOWSHEETS" revealed on 09/20/2014 from 08:55 through 09/21/2014 at 20:00 that patient's "level of consciousness (LOC)" was documented as sedated with periods of calm behavior, agitated/restless, sedated and paralyzed. The medical record revealed there were no times that the restraints were discontinued and least restrictive measures pursued. The medical record further revealed that on 09/22/2014 at 15:00 through 09/23/2014 at 01:00 the LOC was documented as calm or sedated with behaviors ranging from not compliant, combative, sleeping, agitated at which time it was also documented that "law enforcement at bedside". On 09/23/2014 the LOC was documented as sedated with behaviors documented as sleeping and noncompliant. On 09/24/2014 through 10/03/2014 LOC was documented ranging from sedated, sleeping, agitated/restless not compliant and confused with behaviors documented as sleeping, calm, noncompliant, and agitated. On 09/24/2014 through 10/15/2014 LOC was documented ranging from sleeping, calm, awake and alert, agitated, confused, and sedated with behaviors documented ranging from agitated/restless, not compliant, sleeping, calm, and comatose. Restraints were not discontinued at any time that the patient exhibited behaviors that he could be discontinued from restraints or least restrictive measures attempted. The closed medical record revealed that the named patient was in restraints starting on 09/20/2014 until 10/15/2014. There were no restraint orders for the date of 09/21/2015 and the named patient had restraint flowsheet documentation revealing that he was in restraints during that time. The medical record revealed sitter documentation was completed on 09/19/2014, 09/20/2014 and 09/22/2014 when 1:1 was required. The medical record review of the "Interdisciplinary Plan of Care" revealed that that the plan of care did address the use of violent and nonviolent restraints for the named patient. The medical record further revealed neurological assessments completed by the RN while the named patient was in the ICU sedated indicating using the RASS to monitor the degree of sedation. The record revealed RASS documentation for 09/20/2014 -3, 09/21/2014 -3 and -4, 09/22/2014 -4, -3, +1, +2, +3, 09/23/2014 +2, +1, -2, -3, 09/24/2014 -2, +2, 09/25/2014 -2, -3, +2, 0, 09/26/2014 -2, -3, 09/27/2014 -2, -3, 09/28/2014 -3, 09/29/2014 -3, -2, and 09/30/2014 -2, -3. Medical record review of neurological assessments completed for LOC (level of consciousness (a measurement of a person's arousability and responsiveness to stimuli from the environment)) revealed on 09/23/2014 at 08:50 and 13:42 "Obtunded" (the patient has a lessened interest in the environment, slowed responses to stimulation, and tends to sleep more than normal with drowsiness in between sleep states), 09/26/2015 at 08:27 and 13:09 "Comatose" (a state of unarousable unresponsiveness), 09/26/2014 19:37 and 19:26 "Obtunded", 09/27/2015 at 00:21, 06:36, 07:52, and 11:21 "Obtunded", 10/01/2015 at 00:15, 04:30 "Obtunded". The medical record review revealed there was no documentation that consideration of or removal of restraints was considered.
Interview on 11/19/2015 at 10:36 with Charge Nurse (CN) #2 from the ICU who stated she remembered Patient #4 when he was in the ICU in September and October of 2014. Interview revealed the ICU staff had discussed calling law enforcement when they were going to extubate the named patient just to have them on stand-by since he had been so violent and "we all decided because he was unpredictable " .

2. Closed medical record review of Patient #7 revealed a 34 year old female admitted through the facility's emergency department to the intensive care unit on 10/26/2015 for a diagnosis of Xanax Overdose and Suicidal Ideation. Review of the History and Physical revealed the patient intentionally ingested between 12 and 15 1mg Xanax (benzodiazepine- anti-anxiety) tablets. The patient was placed under involuntary commitment status (IVC) at the time of admission. Review of sitter flowsheet documentation revealed at 1315 "Pt con't to be combative unable to comply with directions for safety of self and staff. Security and police present. Pt placed in leather restraints to maintain safety of staff and self." Review of nursing note on 10/26/2015 at 1454 revealed "At 1300 patient became agitated and angry, pulled out IV, got out of bed and grabbed at boyfriends throat, pushed sister against the wall. Pt then banged own head against window. Verbally abusive and threatening physical violence to staff trying to guide patient back to bed. Code gray called, hospitalist called, 911 called. Patient refusing to get in bed, yelling, ripped gown off, pulling at foley. Patient sat on floor refusing to get up. Hospitalist at bedside. Pt assisted back to bed, pt grabbed pillow and held it tight over her face. Violent restraints initated". Review of the Violent or Self-Destructive Restraint Flow Sheet on 10/26/2015 revealed the patient was placed in A-Hard Wrist L, B- Hard Wrist R, M-Hard Ankle L and N-Hard Ankle R at 1300 and the patient's level of consciousness (LOC) was documented as CB-combative and Behavior as AG-agitated. Review of the restraint flow sheet at 1330 revealed the patient's LOC was CB/AG and Behavior was AG. Review of the Medication Administration record revealed the patient was given Geodon (antipsychotic) 20mg intramuscular, thigh left at 1331 (31 minutes after application of 4-point leather restraints). Review of restraint flowsheet revealed the patient LOC and Behavior as SL- Sleeping at 1400-1700 (3 hours) . A new restraint order was obtained at 1700 with the LOC documented as CO-confused and SL-sleeping and Behavior as AG-agitated/ SL-Sleeping. The restraint flowsheet documentation revealed patient LOC and Behavior as SL-Sleeping from 1715-2330(6 hours 15 minutes) with a restraint renewal order at 2100 with a "Indication for restraint: Injury to self: "Banging head on window" Injury to others: "Stricking at staff and family". Record review revealed the patient to be sleeping at the time of the renewal order in A-Hard Wrist L, B- Hard Wrist R, M-Hard Ankle L and N-Hard Ankle R restraints. The medical record review revealed there was no documentation that consideration of or removal of restraints was considered. Review revealed the patient LOC and Behavior was AA- awake and alert at 2345 and CA-calm 2400. Review revealed the patient LOC and Behavior SL-sleeping 0015-0100 on 10/27/2015. Review revealed the patient LOC and Behavior as SL-sleeping from 0100-0430 (3hours 30minutes) and patient remains in A-Hard Wrist L, B- Hard Wrist R, M-Hard Ankle L and N-Hard Ankle R restraints. Review revealed at 0445 the patient's LOC and Behavior as AA- awake and alert. Review revealed a Violent/ Behavioral restraint renewal order at 0500 on 10/27/2015. Review of restraint flow sheet revealed the patient LOC and Behavior at 0500 as AA- awake and alert. Review revealed the patient LOC and Behavior at 0530 was AG- agitated and at 0545-0715 the patient was SL-sleeping. Review revealed at 0730 the patient was awake and alert and calm. The medical record review revealed there was no documentation that consideration of or removal of restraints was considered. Review of Nurses notes on 10/272015 at 0800 revealed "Pt switched from 4-point leather restraints to bilateral soft wrist restraints. Pt calm, cooperative. Explained reason for continuing restraints and criteria for release". Review of restraint flow sheet revealed patient LOC as AA- awake and alert and Behavior as CA-calm. Nurses Notes revealed at 0900 "Pt calm, cooperative. Understands criteria for release of restraints. Restraints removed".
Interview on 11/19/2015 at 10:36 with Charge Nurse (CN) #2 from the intensive care unit (ICU) who stated she remembered Patient #7 when she was in the ICU. Interview revealed the patient was placed in leather restraints and given medication to calm down. Interview further revealed the patient would wake up screaming and was agitated. Interview with CN #2 revealed she could not define or give an example of a patient in a chemical restraint.

NC0011286