HospitalInspections.org

Based on document review and interview, the facility failed to protect and promote patient #1's rights.


A. The facility failed to establish a process through their QAPI program to assess and monitor the use of restraint in the facility's Emergency Room (ER). Patient #1 was restrained with soft wrist and soft ankle restraints while receiving care in the Emergency Room. Patient #1 was not listed on the facility's Restraint Log as having been restrained. The facility's leadership, Chief Nursing Officer (CNO) and Director of Clinical Effectiveness (QAPI), did not have knowledge of patient #1 being restrained in the facility's ER.

Refer to tag A0154


B. The facility failed to ensure physician #1 followed the established restraint policy when ordering restraints for patient #1.

Refer to tag A0168


C. The facility failed to ensure Emergency Room Staff monitored and documented interventions using the established restraint documents and in the correct intervals established by policy.

Refer to tag A0175

Based on document review and interview, the facility failed to follow their established process to assess and monitor the use of restraint in the facility's Emergency Room (ER). The QAPI program failed to identify Patient #1 was placed on soft wrist and soft ankle restraints while receiving care in the Emergency Room. Patient #1 was not listed on the facility's Restraint Log as having been restrained. The facility's leadership, Chief Nursing Officer (CNO) and Director of Clinical Effectiveness (QAPI), did not have knowledge of patient #1 being restrained in the facility's ER.


A review of the document titled Rapid Triage revealed that the patient was a 41 year old female with a stated Complaint of "My psych meds aren't working" patient states "I have been getting frustrated."
Other: Patient angry at her mother and says that she tore stuff at home.


A review of the document titled Emergency Provider Record revealed "Chief Complaint: Hallucinating, agitated. Onset/ duration: today, Intent: psychotic break, severe, Context: situational problems, Associated symptoms: agitated hostile, paranoid and confused. Suicide risk assessment: uncertain risk. Social History: occupation, disabled. Past History: Bipolar, Manic, and Schizophrenic."


A review of patient#1 medical record revealed documentation in Patient Notes on 08/20/2016, at 8:45pm "Pt. walking from bathroom to ER room 14, AskeD the RN for Dinner. Informed patient kitchen is closed but can see if can find something for her to eat. Patient looked over at officer (security) sitting at nurses station and started screaming at him to "don't fucking look at me. You white KKK son of a bitch." Instructed patient to stop screaming and cursing at staff. Escorted back to her room. Able to calm patient with verbal reassurance. Honey bun and orange soda given. Will continue to monitor for anger and aggression. Patient refused medication at this time stating "I am not taking any medicine cause I ain't going to no hospital (sic)." Will continue to attempt to keep patient calm verbally."


A review of patient#1 medical record revealed documentation in Patient Notes on 08/20/2016 at 9:00pm "Patient to room door screaming and cursing at officer (security) at desk. Patient pointing at security and yelling "you are a racist, peckerwood. Don't look at me and Fuck all of Y'all." (sic) Patient instructed to stop cursing to go back to room Patient refused. Patient walked back into room. Restrained while medication given. Soft wrist and ankle restraints applied. Patient bit officer (security) on arm while restraining patient."


Patient Notes on 08/20/2016 at 9:27pm, the patient was out of restraints.


Patient Notes on 08/20/2016 at 9:27pm, the patient was out of restraints.


Patient Notes on 08/20/2016 at 9:35pm, the patient was placed in behavioral soft wrist restraints and soft ankle restraints.


A review of patient#1 medical record revealed documented in an undated Progress Notes but timed at 2:00am " ...had restraints removed ..."


A review of the document titled Restraint Log revealed patient #1 was not listed on the log.



A review of the document titled "Use of Restraints" revealed the following:

4B. Order for restraints with violent or Self-Destructive Behavior.

a. Physician orders for restraint must be time limited, and must specify clinical justification for the restraint .....

11. Performance Improvement:
a. Data on the use of restraint and seclusion is collected to monitor appropriate use and to identify process improvement opportunities.


An interview on 02/28/2017 at approximately 10:45am in the administrative conference room with the Director of Clinical Effectiveness (QAPI) confirmed patient #1 was not listed on the restraint log as having been placed in restraints. The Director of Clinical Effectiveness (QAPI) revealed the ordering physician has to enter the order for restraint in the computer system and this action is what triggers QAPI that a patient was placed in restraints. The Director of Clinical Effectiveness (QAPI) confirmed the physician #1 did not place an order for restraints in computer ordering system.


An interview on 02/28/2017 at approximately 10:45am in the administrative conference room with the Chief Nursing Officer (CNO) confirmed patient #1 was not listed on the restraint log as having been placed in restraints.

Based on record review and interview, the facility failed to ensure physician #1 followed the established restraint policy when ordering restraints for patient #1.


A review of the document titled Rapid Triage revealed that the patient was a 41 year old female with a Stated Complaint: "My psych meds aren't working" patient states "I have been getting frustrated."
Other: Patient angry at her mother and says that she tore stuff at home.

A review of the document titled Emergency Provider Record revealed Chief Complaint: Hallucinating, agitated. Onset/ duration: today, Intent: psychotic break, severe, Context: situational problems, Associated symptoms: agitated hostile, paranoid and confused. Suicide risk assessment: uncertain risk. Social History: occupation, disabled. Past History: Bipolar, Manic, and Schizophrenic.


A review of patient#1 medical record revealed documentation in Patient Notes on 08/20/2016 at 8:45pm Pt. walking from bathroom to ER room 14, Aske the RN for Dinner. Informed patient kitchen is closed but can see if can find something for her to eat. Patient looked over at officer (security) sitting at nurses station and started screaming at him to "don't fucking look at me. You white KKK son of a bitch." Instructed patient to stop screaming and cursing at staff. Escorted back to her room. Able to calm patient with verbal reassurance. Honey bun and orange soda given. Will continue to monitor for anger and aggression. Patient refused medication at this time stating "I am not taking any medicine cause I ain't going to no hospital (sic)." Will continue to attempt to keep patient calm verbally.


A review of patient#1 medical record revealed documentation in Patient Notes on 08/20/2016 at 9:00pm Patient to room door screaming and cursing at officer (security) at desk. Patient pointing at security and yelling "you are a racist, peckerwood. Don't look at me and Fuck all of Y'all." (sic) Patient instructed to stop cursing to go back to room Patient refused. Patient walked back into room. Restrained while medication given. Soft wrist and ankle restraints applied. Patient bit officer (security on arm while restraining patient.


Patient Notes on 08/20/2016 at 9:27pm the patient was out of restraints.


Patient Notes on 08/20/2016 at 9:35pm the patient was placed in behavioral soft wrist restraints and soft ankle restraints.


A review of patient#1 medical record revealed documented in an undated Progress Notes but timed at 2:00am " ...had restraints removed ..."


A review of the document titled "Use of Restraints" revealed the following:

4. Order Restraint
a. An order for restraint must be obtained from a physician who is responsible for the care of the patient ....

4B. Order for Restraints with Violent or Self-Destructive Behavior.
b.Physician orders for restraint must be time limited, and must specify clinical justification for the restraint .....


A review of patient#1 medical record revealed no written or electronic order for restraints.


An interview on 02/28/2017 at approximately 10:45am in the administrative conference room with the Director of Clinical Effectiveness (QAPI) confirmed patient #1 was not listed on the restraint log as having been placed in restraints. The Director of Clinical Effectiveness (QAPI) revealed the ordering physician has to enter the order for restraint in the computer system, this action is what triggers QAPI that a patient was placed in restraints. The Director of Clinical Effectiveness (QAPI) confirmed the physician #1 did not place an order for restraints in computer ordering system.


An interview on 02/28/2017 at approximately 11:45am in the administrative conference room with the Director of the Emergency Department confirmed physician #1 did not follow the established process by not entering an electronic order for the use of restraints on patient #1.

Based on document review and interview, the facility failed to ensure Emergency Room Staff monitored and documented interventions using their established restraint documents and in the correct intervals established by policy.


A review of the document titled Rapid Triage revealed the patient'sStated Complaint: "My psych meds aren't working" patient states "I have been getting frustrated."
Other: Patient angry at her mother and says that she tore stuff at home.


A review of the document titled Emergency Provider Record revealed 41 year old female with Chief Complaint: Hallucinating, agitated. Onset/ duration: today, Intent: psychotic break, severe, Context: situational problems, Associated symptoms: agitated hostile, paranoid and confused. Suicide risk assessment: uncertain risk. Social History: occupation, disabled. Past History: Bipolar, Manic, and Schizophrenic.


A review of patient#1 medical record revealed documentation in Patient Notes on 08/20/2016 at 8:45pm Pt. walking from bathroom to ER room 14, Aske the RN for Dinner. Informed patient kitchen is closed but can see if can find something for her to eat. Patient looked over at officer (security) sitting at nurses station and started screaming at him to "don't fucking look at me. You white KKK son of a bitch." Instructed patient to stop screaming and cursing at staff. Escorted back to her room. Able to calm patient with verbal reassurance. Honey bun and orange soda given. Will continue to monitor for anger and aggression. Patient refused medication at this time stating "I am not taking any medicine cause I ain't going to no hospital (sic)." Will continue to attempt to keep patient calm verbally.


A review of patient#1 medical record revealed documentation in Patient Notes on 08/20/2016 at 9:00pm Patient to room door screaming and cursing at officer (security) at desk. Patient pointing at security and yelling "you are a racist, peckerwood. Don't look at me and Fuck all of Y'all." (sic) Patient instructed to stop cursing to go back to room Patient refused. Patient walked back into room. Restrained while medication given. Soft wrist and ankle restraints applied. Patient bit officer (security on arm while restraining patient.


Patient Notes on 08/20/2016 at 9:27pm the patient was out of restraints.


Patient Notes on 08/20/2016 at 9:35pm the patient was placed in behavioral soft wrist restraints and soft ankle restraints.


Patient Notes on 08/21/2016 at 12:24am revealed ...cooperative, calm, using soft voice


A review of patient#1 medical record revealed documented in an undated Progress Notes but timed at 2:00am " ...had restraints removed ..."
Patient was put in soft wrist and soft ankle restraints on 08/20/2016 at 9:35pm remained in restraints until 08/21/2016 at 2:00am.


An interview on 02/28/2017 at approximately 11:45am in the administrative conference room with the Director of the Emergency Department confirmed Emergency room staff did not follow the established process and did not document patient #1 restraints using the required computer forms.