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Based on review of 10 patient records, 7 of which are emergency department restraint records; it was determined that due to the following standard level deficiencies cited under the Condition of Patient Rights and due to the hospital holding a patient against his will without benefit of an emergency petition or determination of capacity, the Condition Of Patients' Rights was not met as evidenced by:


Patient #7 is a 26-year-old male who on 3/10/12 was brought to the ED via family but for a psychiatric evaluation after being found "wandering around all night." Patient #7 has a history of mental illness, sickle cell disease, and non-compliance with medication. His most recent prior admission was February 2012.

A nursing note of 8:10 am states "Mental Status - Alert, oriented x 3 (person, place, day). Non-cooperative. Patient was walking back from triage and he would stop and at times and look at different postings on the wall then whistle and state he needs to see his aunt missy (in-patient at that time). He did this for 10 minutes. He then looked at his tattoo on his wrist and began crying and stooped down." This was done while walking back to the station. The nurse allowed the patient #7 to call is Aunt.

At 8:18 am, a physician assessed and wrote "Has a delusional thought process." A nursing note of 8:20 am states "Pt given geodon and ativan while standing in hallway. He was then shown to room 301 and he stated he is not going in there. Security here and 3 guards and others took the patient into the room. 4 point restraints were applied. Patient was resistant and needed to be dragged into room." A delusional though process does negate patient #7's right to refuse evaluation and treatment. Restraints were removed at 8:50 am and patient #7 was admitted on two physician certificates.

The hospital Patient Handbook, page 18, Patient Rights & Responsibilities states in part, "You have the right: To refuse treatment."

The hospital General Consent Form, 1. (b) states in part, "I understand I have the right to limit or refuse recommended treatments and /or procedures." There was no general consent or other documentation in the record to indicate that patient #7 was informed of his right to refuse treatment.

While patient #7's behaviors needed further assessment, the hospital made no emergency petition or certifications in order to hold patient for evaluation, nor was a lack of capacity determined. Therefore, patient #7 was held against his will, against his express decision to stay outside the examination room, and against his right to refuse treatment.

Further, it was noted that 2 of 7 patients were not given care in a safe setting as cited at A144; that 1 of 7 patients was not safely monitored as cited at A167; that 2 of 7 patients had no orders for restraint as cited at A168; that the tool used to monitor restraints was not in compliance with federal regulations as noted at A169 ; that 2 of 7 patients were not released from restraints at the earliest possible time as cited at A174 ; and that 5 of 7 restrained patients lacked a face-to-face evaluation that met the criteria identified in A179.

Based on a review of 10 emergency department (ED) patient records, it is revealed that security staff used pepper foam on patient #3 without hospital policy or procedural guidance to govern its use; assess, care for and decontaminate patient #3 after its use; protect other ED patients from contact with the pepper foam, or to decontaminate the area of the ED in which it is sprayed, preventing further unintentional contact with a hazardous chemical. Additionally, employed security staff used law-enforcement hand-cuffs to restrain patients #2 and #3, neither of whom were in police custody.

Patient #2 is a 52-year-old male who presented on 2/1/2012 at 2:42 PM via police emergency petition after stating he would hang himself after they (the police) let him go. In the ED, patient #2 was initially cooperative. A psychiatric note of 3:10 PM states "He has suicidal ideation. On questioning patient has a definite plan for suicide: Patient states he would use narcotics to kill himself." At 3:15 PM, patient #2 was noted to state "I can kill myself just an easily in here." Two Physician Certificates were made for involuntary commitment.

When patient #2 learned he would be transferred to a psychiatric facility, he refused to go. A nursing note of 12:12 am states in part, " ...ambulance crew is here, pt uncooperative to get up from his chair, states "I am not going anywhere, if anybody touches me I am going to start a fight." After the physician spoke with patient #2, he continued to refuse to go.

A nursing note of 12:30 am states, " Per Dr. ___, will try to admit here, PERT calling the psychiatrist at this time. A subsequent nursing note of 12:44 am states " per Dr. ___, pt will be going to (another hospital), will medicate him and transfer him. Pert called back (ambulance crew), will be here in 40 minutes."

A nursing note of 1:11 am states "pt is given Haldol, valium and Benadryl, security x 3 at bedside, pt is cooperative, will wait until pt is asleep for transfer ... " A nursing note of 1:44 am states "pt is transferred to (ambulance) stretcher, pt is sleeping with snoring respirations. A nursing note of 1:55 am states "pt woke up inside the ambulance, tried to punch the ambulance crew, uncooperative, pt is hand cuffed and brought back to the room, placed in 4-point restraint." Per documentation, security used law-enforcement hand cuffs to move patient #2 from the ambulance to the ED room where he was placed in 4-point restraint.

Patient #3 is a 30-year-old male who voluntarily presented on 2/1/2012 at 11:39 PM for a psychiatric evaluation after having cut the volar aspect of his right forearm. This was the second presentation for suicidal ideation in one week. Patient #3 stated he had been involved in 6 fights over the last 3 days. A nursing note of 2/2/2012 at 12:21 states "pt came towards the security, became violent , started fighting, security x 4 grounded the pt to the floor, pepper sprayed , placed in hand cuffs brought to bed and placed on 4 point restraint, called Dr. ___, received vo (verbal order) order for Haldol, Valium and Cogentin."

The physician performed his Review of Systems and the Physical of patient #3 at 0047, three minutes following the restraint process and after the pepper foam was used. The physician eye exam states "Pupils are equal in size, round, reactive to light. Extraocular movements are intact." Under the psychiatric portion of the assessment, the physician wrote "Patient appears anxious." Further physician documentation states "Exam started at 00:47. History comes from patient. Have reviewed and agree with RN note. Hospital records were reviewed. Able to get a good history. 30 y.o. male presents to ED with suicidal thoughts, saying he is having a hard time coping. Pt. ran out of his meds a few days prior. Has homicidal ideations, saying he likes to fight and likes pain. Denies auditory hallucinations. Denies chest pain, sob, abd pain, n, v, dizziness, fevers."

At 1 am, a nursing note states "pt is c/o burning in the eye, unable to open eyes, irrigated both eye with saline, pt is able to open the eyes." No other clinical note reveals an assessment of the patient for injury related to use of pepper foam, or a plan to decontaminate the patient .

A physician note of 5:38 am states in part, "Pt became extremely violent in ED requiring medication to sedate him." No physician notation of the use of pepper foam, eye irritation, the need for patient decontamination, or the fact that patient #3 was restrained is found.

Interview with hospital administrative staff reveals that security staff; some who are security guards, and some who are security police; are all employed by the hospital, and are the only staff that carry and have occasion to use pepper foam and hand-cuffs. However, staff also state there is no policy/procedure/protocol to guide the use of pepper foam in the ED.

Pepper foam is a law-enforcement weapon which contains up to 10% Oleoresin Capsicum (the irritating ingredient in pepper). Pepper foam is oil-based and represents an irritant hazard primarily to lungs, eyes, and skin. Pepper foam may be used in close quarters, or be sprayed variously from 6-10 feet from the user. Though the use of pepper foam vs. pepper spray may reduce the aerosolization of the active ingredient, it does not negate its potential to harm other individuals in the vicinity in which it is sprayed. Pepper foam is a contaminate and requires a decontamination process for the target person and the contact environment .

Per the Security Police and Security Guard Job Descriptions under "Mental Demands" #4 and #5 respectively:

"4. Makes decisions relative to the safety and security of patients, visitors, and employees on Medical Center properties.
5. Makes decisions involving use of that amount of force justified in controlling a dangerous/threatening person or situation. This decision involves mental and judgmental process of immediately prioritizing whether to use deadly force (pistol), nightstick, pepper spray, or hands."

The use of hand-cuffs is not mentioned in the job description.

A review of security staff training reveals Crisis Prevention Institute (CPI) Training, which by definition is the " Safe, non-harmful behavior management system designed to aid health and human service professionals in the management of disruptive and assaultive patients." While CPI training does show participants how to safely put hands-on disruptive/assaultive individuals, no use of pepper spray/foam is found, and restraints are behavioral in nature.

According to their job description, security staff are charged with making decisions for the safety and security of patients, visitors, and employees. Additionally, they are given specific training on how to perform Crisis Prevention. However, and based on the records of patients #2 and #3, it is unclear when and if security staff utilizes CPI training in the management of disruptive/assaultive patients. Consequently, there is a disparity in the hospital expectation of security staff employees to utilize CPI training simultaneous to the hospital job description in which security staff must make decisions as to the use and type of force which may include a pistol, nightstick, and pepper spray or hands.

The hospital fails to identify these disparities, creating an ongoing unsafe environment for ED patients who are not in police custody, yet who may require interventions for behavioral issues, and the patients around them; all who have a right to a safe setting.

Based on a review of 7 restraint records, no monitoring documentation is found for patient #7 during a restraint event as evidenced:


Patient #7 is a 26-year-old male who on 3/10/12 was brought to the ED via family but without an emergency petition for evaluation of a psychiatric condition after being found "wandering around all night." Patient #7 has a history of mental illness, and non-compliance with medication. His most recent prior admission was February 2012.

A nursing note of 8:10 am states "Mental Status - Alert, oriented x 3 (person, place, day). Non-cooperative. Patient was walking back from triage and he would stop and at times and look at different postings on the wall then whistle and state he needs to see his aunt Missy (in-patient at that time). He did this for 10 minutes. He then looked at his tattoo on his wrist and began crying and stooped down." This was done while walking back to the station. The nurse allowed the patient to call is Aunt.

A nursing note of 8:20 am states "Pt given geodon and ativan while standing in hallway. He was then shown to room 301 and he stated he is not going in there. Security here and 3 guards and others took the patient into the room. 4 point restraints were applied. Patient was resistant and needed to be dragged into room." Restraints were removed at 8:50 am and patient #7 was admitted on two physician certificates.

The Code of Maryland Regulations 10.21.12.08 Clinical Interventions During Restraint states in part:
"A. Regardless of the physical setting in which the patient is placed, at a minimum, one staff member shall be assigned continuously while the patient is in a category I restraint.
B. While the patient is restrained, in order to provide appropriate clinical care, at a minimum, staff clinically trained to do so shall:
(1) Keep the patient in full view at all times;
(2) Protect the patient from harm by others;
(3) Closely observe the patient at least every 15 minutes, and document each observation by the observer;"

No Behavioral Restraint/Seclusion Flow Sheet was found in the patient's record to indicate that patient #7 had ongoing assessments, or that he received appropriate care while he was in 4-point restraint.

Based on a review of 7 restraint records out of 10 patient records, it is determined that there was no documented physician orders for the use of restraints for patients #7 and #8 as evidenced by:

Patient #7 is a 26-year-old male who came to the ED on 3/10/12 for a psychiatric evaluation after being found wandering around all night. Patient #7 was being taken from triage to a room which he refused to enter. The nursing note of 8:20 am states "Pt given geodon and ativan while standing in hallway. He was then shown to room 301 and he stated he is not going in there. Security here and 3 guards and others took the patient into the room. 4 point restraints were applied. Patient was resistant and needed to be dragged into room."

Patient #7 was in 4-point restraint from 8:15 until 8:50 am. No order for restraint is found in the record. Interview with a Nursing Manager reveals that the RN who restrained patient #7 remembers obtaining an order, and placing the order on a paper order sheet which went to the behavioral health unit with the patient on admission. However, the order sheet could not be found.

Patient #8 is a 47-year-old female with a history of lung cancer who presented to the emergency department in respiratory distress. Patient #8 was confused, and disoriented. At 12:15 PM, patient #8 received life-saving intubation.

At approximately 2:55 PM, patient #8 was placed in non-violent soft wrist restraints due to the nursing documentation of "Pulling tube." No order is found for this restraint.

The hospital failed to obtain restraint orders for patients #7 and 8.

Based on a review of hospital medical records and restraint logs, it was determined that the hospital allows a trial release of restraints up to sixty minutes without obtaining a new physicians order.


According to the Hospital Restraint Log (HRL), nursing is instructed to document each violent and non-violent restraint, and each seclusion on the HRL. The HRLs are given to a Performance Improvement staff once a month. "Directions" for use of the HRL states in part, " ...Should a patient be given a trial release from restraints, and the trial fails and the patient restraint is reapplied within 60 minutes, it should be considered as a continuation of restraints rather than a new occurrence of restraint. A release of restraint (for a trial or for a restraint alternative such as family presence) that exceeds 60 minutes must be considered and documented as a new event."


Additionally, the Restraint Log form reveals 4 documentation boxes situated horizontally through the middle of the form. Each box is labeled consecutively, "Trial Release Attempted - Day 1 with a box to check if successful or unsuccessful, Trial release Attempted - Day 2" and so on up to Day 4. At the bottom of the form is a note which states in part, "For patients restrained >4 calendar days, document additional trial release on the back of the form (note event #)."


Hospital Policy Alternative to Restraint/Restraints (revised 11/24/10) states in bold print, "PRN restraint orders are not accepted" and makes no reference to trial releases.


Patient #5 is a 22-year-old male who presented to the ED via EMS after being found stumbling, and uncoordinated with slurred speech. Patient #5 had been using alcohol.

At 4:09 am a nursing notes states he was verbally aggressive and tried to swing at staff. He ripped off leads and wires, and staff attempted to calm him. Patient #1 was in restraint for approximately 20 minutes. The nursing Behavioral Restraint/Seclusion Flow sheet for 0435 reveals the nursing documentation of "Trial release. Pt transfer to CT sleeping. Restraints released." In this case, patient #5 did not go back into restraints, though this demonstrates one account of nursing using a trial release.

The hospital process of allowing trial releases does not comply with this regulation.

Based on a review of 10 records, 7 of those records being restraint records, it is revealed that patients #3 and #4 were not taken out of restraint at the earliest possible time.

Review of the hospital's training for release of restraint reveals that the policy states in part, "The patient must be able to cooperate with staff, follow directions, and show a decrease in agitation and an absence of threatening behavior in order for restraints to be removed," and "Remove the restraints one at a time and assess the patient's safety level."

Review of the Behavioral Restraint/Seclusion Flow Sheet (BRSFS) revealed every- 15-minute nursing entries for "Continued Need/Behavioral Observations". At 12:45 am, nursing documented "Pt. fighting." Quotation marks are noted in each of the next two 15-minute assessments indicating patient #3 continued to fight. At 1:30 am and again at 1:45 am, patient #3 is noted as "Calm, sleeping." At 2 am, patient #3 is noted to "Attempting to release restraint" and at 2:15 am under observation, it states "sleeping." On the 2:30 am assessment, the nurse writes "Released right leg restraint." For each of the next three assessments, the nurse writes "Pt. is under observation" without documenting any behavioral information. At 3:30 am, the nurse released the left leg, and then released the right hand at 4 am, and the left hand at 4:15 am.

There is no nursing documentation reveals why after the 1:30 or 1:45 am assessments, when patient #3 was found to be "calm, sleeping," that the nurse failed to release patient #3 from restraint.

Further review of the hospital's Restraint training on "Removal of Restraints" revealed that it states, in part, "Regardless of why patients are restrained, whenever they no longer exhibit the behavior which caused them to be restrained - they are to be immediately released. A physician order is not needed to remove a patient from restraints."

Patient #4 is a 53-year-old male who presented to the ED via ambulance on 2/4/2012 after following a fall down steps with no clear etiology. Patient #4 had an altered mental status, was combative in the ambulance, during transport, and on arrival to the hospital. Patient #4 was placed in 4-point behavioral restraint from 8:20 PM until 11:45 PM.

Review of the Behavioral Restraint/Seclusion Flow Sheet (BRSFS) under continued need/Behavioral Observations reveals only check marks and no behavioral documentation until 11:15 PM when the nurse writes "Pt moving about bed confused." Based on the lack of documentation describing the patient's behaviors, it is not possible to ascertain if patient #4 was released at the earliest possible time.

Based on a review of 7 restraint records, it is determined that 5 of 7, patients # 2, 3, 4, 5, and 7 had no physician, licensed independent practitioner or trained nurse face to face that documented the required elements of a face to face evaluation .

Based on review of the Hospital policy, "Alternative to Restraints/Restraints" under behavioral restraint and seclusion, it was determined by the surveyor to state in part:
"B. Physician Orders: A physician must conduct an initial in-person evaluation of the patient within 4 hours and an in-person re-evaluation of the patient every eight (8) hours for adults or every four (4) hours for ages 17 or less and write a new order if continued restraint is needed."

No physician assessment obligation to perform a Face to Face evaluation within one hour is noted under behavioral restraint and seclusion section of the policy. Likewise, RN training materials reiterate the hospital policy of a 4-hour in-person evaluation by the physician. Additionally, there is no documentation that nursing staff have received the required training to perform the face-to-face evaluations.

The restraint order form states "Face to face assessment by Restraint Trained RN within one hour to place patient in seclusion/restraint (circle one) for up to 4 hours to provide for safety of self or others ... " The order sheet continues "Face to face assessment by MD must write progress note including justification for continuation and discussion with patient and staff how to help patient regain control. May continue seclusion/restraints (circle one) for up to 4 hours to provide for safety of self and others".

Conversely, the Behavioral Restraint/Seclusion Flow Sheet (BRSFS) has multiple prompts for staff. The last prompt states "Face-to-Face Assessment by MD or LIP - Within the 1st hour, then every 8 hours."

Further a review of 5 of 7 records where restraints were employed as an intervention it was noted that the assessments performed by the physicians did not meet the criteria identified in this regulation for a face to face evaluation which must include an assessment of :
1. The patient's immediate situation;
2. The patient's reaction to the intervention;
3. The patient's medical and behavioral condition; and
4. The need to continue or terminate the restraint or seclusion.


Patient #2 is a 52-year-old male who presented on 2/1/2012 at 2:42 PM via police emergency petition after stating he would hang himself after police let him go. In the ED, patient #2 was initially cooperative. A psychiatric note of 3:10 PM states "He has suicidal ideation. On questioning, patient has a definite plan for suicide: Patient states he would use narcotics to kill himself." At 3:15 PM, patient #2 was noted to state "I can kill myself just an easily in here. " A physician examined patient #2 at 3:10 PM. Two physicians certified patient #2 for involuntary admission.

When patient #2 learned he would be transferred to a psychiatric facility, he refused to go and maintained his refusal. A nursing note of 12:12 am states in part, " ...ambulance crew is here, pt uncooperative to get up from his chair, states "I am not going anywhere, if anybody touches me I am going to start a fight." After the physician spoke with patient #2, he continued to refuse to go. A physician note of 2/1 12:22 am states "Unfortunately, at this time, we'll have use chemical restraints to facilitate transfer for further psychiatric care since the patient has expressed both to me and psychiatry he has had thought of killing himself."

A nursing note of 1:11 am states "pt is given Haldol, valium and Benadryl, security x 3 at bedside, pt is cooperative, will wait until pt is asleep for transfer ... " A nursing note of 1:44 am states "Pt is transferred to (ambulance) stretcher, pt is sleeping with snoring respirations. A nursing note of 1:55 am states "pt woke up inside the ambulance, tried to punch the ambulance crew, uncooperative, pt is hand cuffed and brought back to the room, placed in 4-point restraint." Four-point restraints were begun at 1:55 am. A physician note of 2:04 am states in part, "Patient got off the handle (sic) a stretcher, attempted to punch one of the transfer EMS staff, police arrived within seconds and restrained patient, his rhonchi (sic) came to the emergency department and placed into 4-point restraints ... "

While the physician identified both the chemical and 4-point restraints, he did not document the patient's reaction to the intervention, his medical, behavioral condition at the time of restraint, or whether patient #2 needed to remain in restraints.

Patient #3 is a 30-year-old male who voluntarily presented on 2/1/2012 at 11:39 PM for a psychiatric evaluation after having cut the volar aspect of his right forearm. This was the second presentation for suicidal ideation in one week. Patient #3 stated he had been involved in 6 fights over the last 3 days. At 12:21 am, a nursing note states "pt came towards the security, became violent , started fighting, security x 4 grounded the pt to the floor, pepper sprayed, placed in hand cuffs brought to bed and placed on 4 point restraint, called Dr. ___, received vo order for Haldol, valium and Cogentin. Patient #3 was placed in 4-point restraint at 12:44 am."

The physician performed his Review of Systems and the Physical of patient #3 at 0047, three minutes following the restraint process and after pepper foam was used. The physician eye exam states "Pupils are equal in size, round, reactive to light. Extraocular movements are intact." Under the psychiatric portion of the assessment, the physician wrote "Patient appears anxious." Further physician documentation states "Exam started at 00:47. History comes from patient. Have reviewed and agree with RN note. Hospital records were reviewed. Able to get a good history. 30 y.o. male presents to ED with suicidal thoughts, saying he is having a hard time coping. Pt. ran out of his meds a few days prior. Has homicidal ideations, saying he likes to fight and likes pain. Denies auditory hallucinations. Denies chest pain, sob, abd pain, n, v, dizziness, fevers."

The physician's documentation does not indicate that patient #3 was in restraint. Additionally, a physician note of 5:38 am states in part, "Pt became extremely violent in ED, requiring medication to sedate him." Again, the physician's documentation failed to address the fact that the patient had been pepper foamed, handcuffed and subsequently restrained or an assessment of he responded to this interventions as required by this regulation

Patient #4 is a 53-year-old male who presented to the ED on 2/4/12 following a fall down steps with no clear etiology. Patient #4 was noted as combative in the ambulance and during transport. Ambulance staff placed him in restraints. On entry to the hospital, an order for behavioral restraints was written at 8:20 PM, and he was released at 11:45 PM.

A physician note of 8:27 PM notes in part, "We were unable to obtain an accurate HP/ROS due to the patient's combative condition." Likewise, the 8:47 PM psychiatric portion of the Physical Exam notes "The patient is combative and agitated." The physician note does not address that patient #4 was in 4-point restraint and the need to continue to be restrained and therefore, does not address the required elements of the face-to-face evaluation.

Patient #5 is a 22-year-old male who presented to the ED on 3/4/2012 at 4:06 am via EMS after being found stumbling, and uncoordinated with slurred speech. Patient #5 had been using alcohol. At 4:09 am a nursing notes states patient #5 was verbally aggressive and tried to swing at staff. He ripped off leads and wires, and staff attempted to calm him. Patient #1 was in restraints from 4:14 am until 4:35 am.

A physician note of 4:20 am states "(Patient) is a 22 year old male presenting to the ED with an change in his LOC (level of consciousness). The patient appears intoxicated and a complete history is not available. The patient was brought in via EMS who state he was found at a party apparently unconscious. EMS states that patient was able to be aroused when they arrived and his color was normal. Patient answers all questions about tonight as " I don't know" Patient combative during exam."

A nursing note of 4:20 am states "Pt verbally calmed. States he will no longer be uncooperative and combative and does not wish harm against that staff. Security has left the room. Patient remains in restraints. " At 4:24 am, patient #5 is noted to be " Sleeping. " At 4:35 am, he was removed from restraint and taken for a CT.

No physician documentation addresses that patient #5 was in 4-point restraints.

Patient #7 is a 26-year-old male who on 3/10/12 was brought to the ED via family but without an emergency petition for evaluation of a psychiatric condition after being found " wandering around all night." Patient #7 has a history of mental illness, and non-compliance with medication. His most recent prior admission was February 2012.

A nursing note of 8:10 am states, " Mental Status - Alert, oriented x 3 (person, place, day). Non-cooperative. Patient was walking back from triage and he would stop and at times and look at different postings on the wall then whistle and state he needs to see his aunt Missy (in-patient at that time). He did this for 10 minutes. He then looked at his tattoo on his wrist and began crying and stooped down. " This was done while walking back to the station. The nurse allowed the patient to call is Aunt.

A nursing note of 8:20 am states, " Pt given geodon and ativan while standing in hallway. He was then shown to room 301 and he stated he is not going in there. Security here and 3 guards and others took the patient into the room. 4 point restraints were applied. Patient was resistant and needed to be dragged into room. " Restraints were removed at 8:50 am and patient #7 was admitted on two physician certificates.

A physician note of 7:56 am states "Patient has a long history of sickle cell disease, also psychosis, polysubstance abuse. Patient was recently admitted to the psych unit February of this year."

A physician note of 8:19 am states in part, "Exam started at 08:19 " and, "The patient is uncooperative and therefore unable to give a reliable history." A physician note of 08:28 states "The patient was sedated with Geodon and Ativan and was then restrained using soft restraints for his safety."

While the physician notes acknowledge patient #7's immediate situation, the physician does not address the patient's medical condition, e.g. the possible exacerbation of sickle cell disease related to the restraining process. Further, behavioral documentation states "Is quite agitated and aggressive" but does not describe the actual behaviors of patient #7. Additionally, no physician documentation is found for patient #7's reaction to the restraint or the need to continue or terminate restraint.

Based on a review of the hospital restraint policy, the hospital Restraint Log, security staff crisis training vs. actual practice, and 7 restraint records, the hospital has not identified, these areas as requiring analysis, tracking and improvement for the safe management of patients who are determined to require behavioral interventions.


Hospital policy "Alternatives to Restraint/Restraint" does not include guidance on performing the Face-to-Face within the first hour for behavioral restraints.


The Restraint Log is a quality tool used by nursing to document all seclusion/restraint events. The Restraint Log is passed to the Performance Improvement Committee on a monthly basis. Elements on the Restraint Log include data such as the type, reason, device used, alternatives attempted, the date and time of restraint application, and date and time removed. The form does not address whether an order was obtained as cited in tag A=168, whether a face-to-face was completed within the first hour as cited in A-179, or if the patient was taken out at the earliest possible time as cited in A-174.


Additionally, included in the Restraint Log, are instructions on performing a trial release as referenced in tag A-169 which is tantamount to using restraint/seclusion orders on a prn basis.


The hospital employs both security guards, and security police. Part of their training is in Crisis Prevention, the "Safe, non-harmful behavior management system designed to aid health and human service professionals in the management of disruptive and assaultive patients." However, record review indicates that the security staffs choose and use police enforcement weapons and tools such as pepper foam and hand-cuffs rather than Crisis Prevention training in the management of patients who require intervention for behavioral issues. There is documentation of hospital tracking or data of these actions and their impact on patients.


The Quality Assurance, Performance Improvement Departments are not monitoring policy and all requirements associated with restraint/seclusion use. Additionally they fail to monitor the actions of the hospital security staff when they are involved assisting the nursing staff with managing patient behaviors.

Review of 7 patient restraint records reveals that the physician did not authenticate a verbal restraint order until 11 days following the restraint.


Patient #4 is a 53-year-old male who presented to the ED on 2/4/12 following a fall down steps with no clear etiology. Patient #4 was noted as combative in the ambulance and during transport. Ambulance staff placed him in restraints. On entry to the hospital, an order for behavioral restraints was written at 8:20 PM, and he was released at 11:45 PM.

Review of the record reveals a verbal order dated 2/4/2012 at 20:04 which was not authenticated until 2/15/2012 at 1:40 PM.

It should be further noted that under the Code of Maryland Regulations (COMAR 10.21.12.10A(2) ) verbal orders for restraints must be signed within 24 hours of being written.