HospitalInspections.org

Based on document review, observation and interview, the hospital failed to ensure the use of restraint was authorized by the order of a physician of LIP (licensed independent practitioner) for one (1) patient (P10).

Findings:

1. Review of the policy titled Seclusion and Restraint indicated the following:
a. The patient has the right to be free of Seclusion and Restraint of any form. Restraints are utilized only in emergent or crisis situations...
b. Definitions - Restraint: Any manual method, physical or mechanical device...that immobilizes or reduces the ability of a patient to move his/her arms, legs, body or head freely. Physical holds utilizing CPI (Crisis Prevention Institute/Intervention) techniques are considered restraints. Physical Escorts that apply more than a light touch to redirect are considered restraints.
c. A physician or Licensed Independent Practitioner (LIP) can authorize (order) the use of Seclusion and/or restraint.
d. An RN can initiate the emergent use of Seclusion and/or Restraint until a physician or LIP order is obtained.
e. For any patient placed in seclusion and/or restraint,...documentation is required in the Medical Record (18 items listed)
f. A physician or LIP is required to authorize (order) the use of Seclusion and/or Restraint prior to or in an emergent situation.
g. The policy was last revised May 2016.

2. Review of medical staff (MS) Rules and Regulations indicated the following for Seclusion and/or Restraint:
a. Restraint is defined as any method (chemical or physician) [sic] of restricting an individual's freedom of movement, including physical activity or normal access to his or her body...
b. The use of restraint must be in accordance with the order of a physician or LIP...
c. The Bylaws/Rules & Regulations were approved and effective 2/6/15.

3. On 5/31/16 at 2:00 pm, in the presence of A2, Director of Quality Assurance, during adolescent group therapy observation on the adolescent unit, in the common area, the following was observed: Eleven (11) adolescent appearing patients were seated in the area and being led in a group style session by a staff member/therapist. A staff member was seated at the far end of the hall. One child (P10) was observed to be near the common area/adolescent group therapy meeting area occasionally peering around the corner. A staff member (S2) was positioned at this end of the hall. S2 spoke to P10 and then went with the child into a room/office out of sight. At 2:15 pm S2 exited the room/office with P10. S2 was walking behind P10 with his/her arms wrapped around P10 with P10's arms crossed in front and held in place. P10 was taken to the Time Out/Quiet Room. A2 soon followed S2 and P10 into the room. S2 and A2 remained in the room and informed P10 he/she could leave when he/she agreed to attempt participation in the group session. P10 voiced feeling uncomfortable in the big kid group and stated he/she did not understand what they were talking about. At 2:25 pm P10 agreed to re-attempt group participation with the adolescents and was escorted out of the room.

4. On 5/31/16 at 2:30 pm, A2 indicated P10 was refusing to participate in the group session and was being defiant and was therefore taken by S2 to the Time Out Room.

5. On 6/1/16 at 9:00 am, A2 indicated S2 was a MHT (mental health technician) and that no order for restraint needed to have been obtained due to no restraint being implemented. A2 indicated an order is only needed when a 4 point restraint is used. A2 further indicated that S2 was escorting P10 to the quiet room with his/her arms wrapped around the child in order to de-escalate a potentially unsafe situation.

6. Review of P10's medical record (MR) lacked documentation of a physician or LIP order for restraint between 5/31/16 2:00 pm and 6/1/16 1:30 pm.

7. On 6/1/16 at 1:30 pm, A1, Chief Administrative Officer, indicated the MR of P10 did not have MHT or nursing documentation of the event observed on 5/31/16 or any time out between 2:00 pm and 2:30 pm on that date and lacked documentation of an order for restraint on 5/31/16.

Based on document review, observation and interview, the hospital failed to document patient behavior and intervention used for restraint of one (1) patient (P10).

Findings:

1. Review of the policy titled De-Escalation of Aggressive Behavior indicated the following:
a. Center leadership emphasizes the use of therapeutic de-escalation techniques in response to an angry or potentially aggressive patient prior to use of more restrictive interventions.
b. De-escalation strategies include responding in a caring, non-authoritarian manner during a behavioral crisis.
c. Observe for signs, symptoms or target behaviors that indicate increased agitation...and notify the RN (registered nurse), Social Worker, Therapeutic Services and/or the Physician/Nurse Practitioner.
d. Avoid power struggles...
e. Avoid confrontation words such as "you will", "you must", and "or else".
f. Documentation: A progress note is made by the staff and includes: Date, time and problem number/title. Factual information... The patient's response to the interventions.
g. The policy was last reviewed September 2013.

2. Review of the policy titled Seclusion and Restraint indicated the following:
a. The patient has the right to be free of Seclusion and Restraint of any form. Restraints are utilized only in emergent or crisis situations...
b. Definitions - Restraint: Any manual method, physical or mechanical device...that immobilizes or reduces the ability of a patient to move his/her arms, legs, body or head freely. Physical holds utilizing CPI (Crisis Prevention Institute/Intervention) techniques are considered restraints. Physical Escorts that apply more than a light touch to redirect are considered restraints.
c. A physician or Licensed Independent Practitioner (LIP) can authorize (order) the use of Seclusion and/or restraint.
d. An RN can initiate the emergent use of Seclusion and/or Restraint until a physician or LIP order is obtained.
e. For any patient placed in seclusion and/or restraint,...documentation is required in the Medical Record (18 items listed)
f. A physician or LIP is required to authorize (order) the use of Seclusion and/or Restraint prior to or in an emergent situation.
g. The policy was last revised May 2016.

3. On 5/31/16 at 2:00 pm, in the presence of A2, Director of Quality Assurance, during adolescent group therapy observation on the adolescent unit, in the common area the following was observed: Eleven (11) adolescent appearing patients were seated in the area and being led in a group style session by a staff member/therapist. A staff member was positioned at the far end of the hall. One child (P10) was observed to be more near the common area/adolescent group therapy meeting area occasionally peering around the corner. A staff member (S2) was also seated at this end of the hall. S2 spoke to P10 and then went with the child into a room/office out of sight. At 2:15 pm, S2 exited the room/office with P10. S2 was walking behind P10 with his/her arms wrapped around P10 with P10's arms crossed in front and held in place. P10 was taken to the Time Out/Quiet Room. A2 soon followed S2 and P10 into the room. S2 and A2 remained in the room and informed P10 he/she could leave when he/she agreed to attempt participation in the group session. At 2:25 pm, P10 agreed to re-attempt group participation with the adolescents and was escorted out of the room.

4. On 5/31/16 at 2:30 pm, A2 indicated P10 was refusing to participate in the group session and was being defiant and was therefore taken by S2 to the Time Out Room.

5. Review of P10's medical record (MR) lacked documentation of the intervention observed or de-escalation interaction between S2 and P10 between 5/31/16 2:00 pm and 6/1/16 1:30 pm. The MR also lacked documentation of P10s response to the intervention/restraint.

6. On 6/1/16 at 1:30 pm, A1, Chief Administrative Officer, indicated the MR of P10 did not have MHT or nursing documentation of the event observed on 5/31/16 or any time out between 2:00 pm and 2:30 pm on that date.

Based on document review, observation and interview, the hospital failed to document, in the medical record, alternatives or less restrictive interventions attempted prior to the use of restraint for one (1) patient (P10).

Findings:

1. Review of the policy titled De-Escalation of Aggressive Behavior indicated the following:
a. Center leadership emphasizes the use of therapeutic de-escalation techniques in response to an angry or potentially aggressive patient prior to use of more restrictive interventions.
b. De-escalation strategies include responding in a caring, non-authoritarian manner during a behavioral crisis.
c. Observe for signs, symptoms or target behaviors that indicate increased agitation...and notify the RN (registered nurse), Social Worker, Therapeutic Services and/or the Physician/Nurse Practitioner.
d. Avoid power struggles...
e. Avoid confrontation words such as "you will", "you must", and "or else".
f. Documentation: A progress note is made by the staff and includes: Date, time and problem number/title. Factual information... The patient's response to the interventions.
g. The policy was last reviewed September 2013.

2. On 5/31/16 at 2:00 pm, in the presence of A2, Director of Quality Assurance, during adolescent group therapy observation on the adolescent unit, in the common area the following was observed: Eleven (11) adolescent appearing patients were seated in the area and being led in a group style session by a staff member/therapist. A staff member was seated at the far end of the hall. One child (P10) was observed to be more near the common area/adolescent group therapy meeting area occasionally peering around the corner. A staff member (S2) was also seated at this end of the hall. S2 spoke to P10 and then went with the child into a room/office out of sight. At 2:15 pm, S2 exited the room/office with P10. S2 was walking behind P10 with his/her arms wrapped around P10 with P10's arms crossed in front and held in place. P10 was taken to the Time Out/Quiet Room. A2 soon followed S2 and P10 into the room. S2 and A2 remained in the room and informed P10 he/she could leave when he/she agreed to attempt participation in the group session. At 2:25 pm, P10 agreed to re-attempt group participation with the adolescents and was escorted out of the room.

3. On 5/31/16 at 2:30 pm, A2 indicated P10 was refusing to participate in the group session and was being defiant and was therefore taken by S2 to the Time Out Room.

4. On 6/1/16 at 9:00 am, A2 indicated that S2 was escorting P10 to the quiet room with his/her arms wrapped around the child in order to de-escalate a potentially unsafe situation.

5. Review of P10's medical record (MR) lacked documentation of intervention or de-escalation interaction between S2 and P10 between 5/31/16 2:00 pm and 6/1/16 1:30 pm. The MR also lacked documentation of P10s response to the intervention.

6. On 6/1/16 at 1:30 pm, A1, Chief Administrative Officer, indicated the MR of P10 did not have MHT or nursing documentation of the event observed on 5/31/16 or any time out between 2:00 pm and 2:30 pm on that date.

Based on observation, document review and interview, the hospital failed to ensure staff ability to demonstrate competency in the application of restraints for 2 of 2 staff members.

Findings:

1. Review of the policy titled Seclusion and Restraint indicated the following:
a. The patient has the right to be free of Seclusion and Restraint of any form. Restraints are utilized only in emergent or crisis situations...
b. Definitions - Restraint: Any manual method, physical or mechanical device...that immobilizes or reduces the ability of a patient to move his/her arms, legs, body or head freely. Physical holds utilizing CPI (Crisis Prevention Institute/Intervention) techniques are considered restraints. Physical Escorts that apply more than a light touch to redirect are considered restraints.
c. An RN can initiate the emergent use of Seclusion and/or Restraint until a physician or LIP order is obtained.
d. For any patient placed in seclusion and/or restraint,...documentation is required in the Medical Record (18 items listed)
e. A physician or LIP is required to authorize (order) the use of Seclusion and/or Restraint prior to or in an emergent situation.
f. Training Requirements: All direct care staff are trained in safe implementation of seclusion and restraint. This includes return demonstration of the application of restraints.
g. The policy was last revised May 2016.

2. On 5/31/16 at 2:00 pm, in the presence of A2, Director of Quality Assurance, during adolescent group therapy observation on the adolescent unit, in the common area the following was observed: Eleven (11) adolescent appearing patients were seated in the area and being led in a group style session by a staff member/therapist. A staff member was positioned at the far end of the hall. One child (P10) was observed to be more near the common area/adolescent group therapy meeting area occasionally peering around the corner. A staff member (S2) was also positioned at this end of the hall. S2 spoke to P10 and then went with the child into a room/office out of sight. At 2:15 pm, S2 exited the room/office with P10. S2 was walking behind P10 with his/her arms wrapped around P10 with P10's arms crossed in front and held in place. P10 was taken to the Time Out/Quiet Room. A2 soon followed S2 and P10 into the room. S2 and A2 remained in the room and informed P10 he/she could leave when he/she agreed to attempt participation in the group session. At 2:25 pm, P10 agreed to re-attempt group participation with the adolescents and was escorted out of the room.

3. On 6/1/16 at 1:00pm, A2 indicated return demonstration of CPI training techniques was not done as part of training.

4. Review of personnel files for S2 and A2 indicated both had CPI training by evidence of a written test. The personnel records lacked documentation of return demonstration for application of restraints/physical hold.