HospitalInspections.org

Based on staff interviews and record review the facility failed to obtain a physician's order for the use of behavioral health restraints during two separate encounters on the same day in the Emergency Department for 1 of 5 applicable patients. ( Patient #1) Findings include:

Per record review Patient #1 arrived to the Emergency Department (ED) with altered mental status on two separate visits on 5/24/16. Per review of the provider notes from the initial visit on 5/24/15 at 03:37 AM, Patient #1 approached the scene of an accident, exhibiting bizarre behavior and eventually admitted to drug use. S/he was found to have benzodiazepines in his/her possession and admitted to smoking marijuana. Patient#1 was acting so " weird " that s/he was taken into protective custody and brought to the ED by police for medical clearance. Patient #1 was hostile, screaming and threatening to staff. Per review of nursing notes from initial visit on 5/24/16 at 03:37 AM, Patient#1 had escalating behavior while in the ED waiting room and the nurse was unable to de-escalate his/her behavior with verbal communication. A stretcher with restraints attached was brought out to the waiting room and Patient #1 was given the option to get on the stretcher by his/her own free will. Patient#1 was assisted to the stretcher by hospital and security personnel. Patient #1 continued to escalate and was put into 4 point restraints; and then a 5th point restraint for safety. After Patient #1 was medically cleared, s/he was discharged into police custody for detoxification. Per review of the provider notes from Patient #1 ' s subsequent visit on 5/24/16 at 06:11 AM, Patient #1 returned to the ED via Emergency Medical Service (EMS), in protective custody; and had exhibited vague self-harm actions and remarks while in the correctional facility. The nursing notes from the subsequent visit on 5/24/16 at 06:11 AM, state Patient#1 was " thrashing around, yelling, screaming, swearing, refusing vital signs and threatening staff " . Upon further review of the provider notes, Patient#1 was placed on a stretcher; and while attempting to place him/her in 4 point restraints his/her agitation and combativeness increased; and Patient#1 became dangerous to staff and himself/herself requiring chemical intervention.

Per review of the physician's orders for Patient #1's initial visit, on 5/24/16 at 03:37 AM, there was no evidence that an order for behavioral health restraints was written. Per review of the physician's orders on 5/24/16, of Patient #1's subsequent visit at 06:11 AM, there was an order written for Constant Observation (direct eyes on the patient), however, there was no evidence that an order had been written for the behavioral health restraints that were applied.

Per interview on 9/6/16 at 3:30 PM with the Emergency Department Nurse Manager, s/he confirmed that on 5/24/16, for Patient #1's initial visit at 03:37 AM, there was no physician order written for behavioral health restraints. S/he further confirmed that on the second visit for Patient #1 at 06:11 AM on 5/24/16, there was a physician's order written for constant observation and no physician order written for behavioral health restraints.

Per review of the policy, Restraints for Medical/Surgical and Behavioral Health Indications on Non-Psychiatric Units Last reviewed on: 12/19/14 "RN (Registered Nurse) responsibility immediately after initiating a Behavioral Health Restraint (BHR), inform the Resident/Physician of the time the BHR was initiated, the need for a face to face assessment of the patient and an order entry in PRISM (The facility's Electronic Medical Record) for BHR."

Based on staff interviews and record review the ED staff failed to perform ongoing monitoring and assessment of a patient's condition (Patient #1), while in behavioral health restraints during an initial visit to the ED on 5/24/16. Findings include:

Per record review Patient #1 arrived in the Emergency Department (ED) with altered mental status on two separate visits on 5/24/16. Per review of the provider notes from the initial visit on 5/24/15 at 03:37 AM, Patient #1 approached the scene of an accident, exhibiting bizarre behavior and eventually admitted to drug use. S/he was found to have benzodiazepines in his/her possession and admitted to smoking marijuana. Patient#1 was acting so " weird " that s/he was taken into protective custody and brought to the ED by police for medical clearance. Patient #1 was hostile, screaming and threatening to staff. Per review of nursing notes from initial visit on 5/24/16 at 03:37 AM, Patient#1 had escalating behavior while in the ED waiting room and the nurse was unable to de-escalate his/her behavior with verbal communication. A stretcher with restraints attached was brought out to the waiting room and Patient #1 was given the option to get on the stretcher by his/her own free will. Patient#1 was assisted to the stretcher by hospital and security personnel. Patient #1 continued to escalate and was put into 4 point restraints; and then a 5th point restraint for safety. After Patient #1 was medically cleared, s/he was discharged into police custody for detoxification.

Per review of the nursing flow sheets and nursing notes for Patient #1's initial visit on 5/24/16 at 0337, there was no evidence of ongoing monitoring and assessment of the Patient #1's condition while in behavioral health restraints. The Restraints for Medical/Surgical and Behavioral Health Indications on Non-Psychiatric Units Last reviewed on: 12/19/14 policy states, "Every 15 minutes that the patient is in restraints, the RN or staff member (Mental Health Technician, Licensed Nursing Assistant), under the supervision of the RN will monitor the physical and psychological state and comfort of the patient. Document any actions taken. Every one hour, the RN will re-assess the need to continue or discontinue the restraint, and will document the assessment and the rationale for his/her decision. Every one hour, the RN or designated staff member will monitor the following indicators of circulatory status of limbs, hands and feet distal to the restraint: color, sensation, temperature and movement, and document their findings and any actions taken. Every two consecutive hours that a patient is in restraint, an RN or designated staff will perform the following actions and document them: active or passive range of motion by releasing one limb at a time and position changes, monitor skin integrity, offer fluids, offer elimination, provide hygiene as needed, and take vital signs."

Per interview on 9/6/16 at 3:30 PM with the Emergency Department Nurse Manager, s/he confirmed that on 5/24/16, for Patient #1's initial visit at 03:37 AM, there was no evidence on the nursing flow sheets and/or nursing notes that identified ongoing assessment and monitoring of Patient #1's condition, while in behavioral health restraints.

Based on staff interviews and record review the Emergency Department (ED) staff failed to document a patient's condition (Patient #1) following the use of behavioral health restraints during an initial visit to the ED on 5/24/16. There was also a failure by ED staff to document an assessment of alleged bruising of a patient following the use of restraints (Patient #3). Findings include:

1. Per record review Patient #1 arrived in the Emergency Department (ED) with altered mental status on two separate visits on 5/24/16. Per review of the provider notes from the initial visit on 5/24/15 at 03:37 AM, Patient #1 approached the scene of an accident, exhibiting bizarre behavior and eventually admitted to drug use. S/he was found to have benzodiazepines in his/her possession and admitted to smoking marijuana. Patient#1 was acting so " weird " that s/he was taken into protective custody and brought to the ED by police for medical clearance. Patient #1 was hostile, screaming and threatening to staff. Per review of nursing notes from initial visit on 5/24/16 at 03:37 AM, Patient#1 had escalating behavior while in the ED waiting room and the nurse was unable to de-escalate his/her behavior with verbal communication. A stretcher with restraints attached was brought out to the waiting room and Patient #1 was given the option to get on the stretcher by his/her own free will. Patient#1 was assisted to the stretcher by hospital and security personnel. Patient #1 continued to escalate and was put into 4 point restraints; and then a 5th point restraint for safety. After Patient #1 was medically cleared, s/he was discharged into police custody for detoxification.

Per review of the nursing flow sheets and nursing notes for Patient #1's initial visit on 5/24/16 at 0337, there was no evidence of ongoing monitoring and assessment of Patient #1's condition while in restraints. The Restraints for Medical/Surgical and Behavioral Health Indications on Non-Psychiatric Units Last reviewed: 12/19/14 policy states, " Every 15 minutes that the patient is in restraints, the RN or staff member (Mental Health Technician, Licensed Nursing Assistant), under the supervision of the RN will monitor the physical and psychological state and comfort of the patient. Document any actions taken. Every one hour, the RN will re-assess the need to continue or discontinue the restraint, and will document the assessment and the rationale for his/her decision. Every one hour, the RN or designated staff member will monitor the following indicators of circulatory status of limbs, hands and feet distal to the restraint: color, sensation, temperature and movement, and document their findings and any actions taken. Every two consecutive hours that a patient is in restraint, an RN or designated staff will perform the following actions and document them: active or passive range of motion by releasing one limb at a time and position changes, monitor skin integrity, offer fluids, offer elimination, provide hygiene as needed, and take vital signs."

Per interview on 9/6/16 at 3:30 PM with the Emergency Department Nurse Manager, s/he confirmed that on 5/24/16, for Patient #1's initial visit at 03:37 AM, there was no evidence on the nursing flow sheets and/or nursing notes that identified ongoing monitoring and assessment of Patient #1's condition, while in behavioral health restraints.

2. Per record review, Patient #3 was being held involuntarily in the ED pending inpatient hospital placement. Per nursing note review, on 6-2-16 at 19:10, the patient was placed in 4 point restraints for behaviors that threatened harm to self and others, "...swinging at staff, spitting and kicking staff ..." During the application of restraints, the patient "...pulled [his/her] arms out of the arm restraints and they were reapplied." On 6/3/16 at 3:26 AM, Nurse #1 documented that Patient #1 was "Blaming me specifically because [s/he] has bruises on [his/her] arms from being restrained earlier." On 6/3/16 at 9:00 AM, Nurse #2 documented, "Spoke with patient as [s/he] showed me bruises on [his/her] left arm ..." Per record review, there was no documentation in either nursing note to indicate that an assessment of the bruising was completed to include the specific location and size of the bruises or whether functional use of the arm(s) was affected. Per interview with the ED Nurse Manager (NM) on 9/6/16 at 3:15 PM, s/he confirmed that there was no evidence in the progress notes that the nurses documented an assessment of the bruising. The NM further stated that s/he would have expected the nurses to communicate the alleged bruising to a provider to be assessed and there was no evidence that this was done.