HospitalInspections.org

Based on staff interviews and record reviews, the Critical Access Hospital failed to assure that its health care services were furnished in accordance with written policies and procedures for 3 of 10 patients in the total sample who received care in the ED (Emergency Department). (Patients #1, #3 and #4). Findings include:

1. Upon arrival in the ED, Patient #1 was assessed to require restraints for the safety of themselves and others. The physician (MD) who ordered restraints failed to initiate new orders for changes in the restraint application while the patient was cared for on 3/8/19. The patient arrived in police protective custody for suicidal ideation with a plan, and was attempting to elope from the ED, combative to staff and screaming. The MD arrived in the room and the patient refused to calm down and cooperate with staff, physically combative and posing a safety risk to his/herself and others present. During interview on 5/6/19 at 3:25 PM, the MD confirmed that s/he had written orders for 4 point restraints after the patient would not stop screaming, yelling, and had twice attempted to elope from the ED (confirmed also in the MD notes).
Later (at 2108 HR.), when the patient had calmed some, nurses documented that 2 restraints (ankles) were removed. Some time later, the patient again exhibited unsafe disruptive behaviors and the patient was again placed in 4 point restraints for safety. Per review, the only written mechanical restraint order in the medical record, dated 3/8/19 at 2054 HR. stated: "Restraints stat...reason: patient safety, type of restraint: wrist. When asked about the order stating 2 point rather than 4 point mechanical restraints, the MD stated that the orders were modified when 2 restraints were removed, thus stated 'wrist' only. The MD confirmed that they had not written a new order for the 4 point restraints after the patient had escalated behaviors requiring a change from 2 point to 4 point restraints.
The failure to write orders for the new initiation of 4 point restraints was not in accordance with the hospital policy Restraint and Seclusion Policy. Under the section Use of Restraint or Seclusion: Violent/Self-Destructive Behavior, P. 3, PP. 2, Staff cannot discontinue a restraint or seclusion intervention, and then re-start it under the same order.
During interview on 5/6/19, the QA staff confirmed that the MD 's order was not in accordance with the hospital's restraint policy/procedure for restraint orders.

2. Per record review and staff interviews, mechanical restraints were not released at the earliest possible time for the following 2 ED patients in the sample.
a. Per record review on 5/6/19, Patient #1 was placed into 4 point restraints by the RN (Registered Nurse) to protect the patient and staff due to highly combative and self- harming behaviors, and multiple attempts at elopement from the ED. The patient was brought to the ED by 2 police and was in protective custody. The reporter who called police said the patient was combative, yelling and agitated and had a plan to harm themselves. Upon review in the ED, the Provider placed stat orders for 4 point mechanical restraints for Patient #1 on 3/8/19 at 2054 Hr. Per review, the staff every 15 minute documentation of 1:1 observations, showed that the patient was in 4 point restraints at 2045 HR. Further documentation showed that 2 of the 4 restraints were released at 2108. At 2245 HR., the flow sheet stated that the "pt appears to be sleeping at this time"; at 2259 HR., "pt is sleeping at this time...". All documentation noted that the patient was sleeping from 2311 HR. on 3/8/19 to 0001 HR. on 3/9/19. A nursing progress note dated 3/9/19 at 0002 HR. documented "upper extremity restraints removed restraints at this time...Patient not happy about being in restraints." The restraints remained on during a time period that the patient was sleeping and not at risk of imminent harm to self or others, in violation of the hospital's restraint policy/procedure.
During interview (5/6/19 at 3:45 PM) the RN providing care to the patient on 3/8/19 confirmed that the patient was asleep for a period of time while in restraints and that s/he did not discontinue the restraints because 'the patient might awaken during the process'. The justification for continuing the restraints was not in accordance with the policy, as stated above, since there was no unsafe situation for a period of over 1 hour, per medical record documentation. The Quality Assurance (QA) staff confirmed during interview on 5/7/19 at 2:00 PM that the restraints should have been removed after it was determined that the patient was asleep and no longer a safety risk.

b. On 4/10/19 at 12:59 Patient #3 was brought to the ED by police for a psychiatric evaluation after demonstrating threatening and aggressive behaviors in the community which were precipitated by command hallucinations. After first agreeing to voluntarily accept psychiatric hospitalization, Patient #3 demonstrated increased agitation and threatened staff. A Code Gray (behavioral emergency response) was called at 16:47 and restraints were ordered by the ED provider at 17:06. Per review of the 15-minute observation documentation completed by assigned Continuous Patient Safety Observer (CPSO) notes at 18:24 the patient's behavior is noted to be "cooperative, crying" and mood description as "calm, sad". From 18:38 through 19:24 Patient #3's behavior and mood continued to remain "calm and cooperative". Although the patient had not demonstrated harm to self or others and remained "cooperative, calm & relaxed" at 19:40 staff release only 2 of the 4 restraints. It was not until 20:25 staff removed the 2 remaining restraints. The delay in discontinuing restraints at the earliest possible time was confirmed with the Director of Operations for the ED on 5/7/19 at 2:05 PM.

The hospital policy entitled Restraint and Seclusion Policy, under Policy:, 7) Restraint or seclusion use is to be discontinued at the earliest possible time when there is no longer adequate and appropriate justification for continued use. Additional guidelines in the policy under Termination of Restraint or Seclusion, 1) "Restraint or seclusion will be terminated a the earliest possible time regardless of the length of time identified in the order. Restraint or seclusion may only be employed while the unsafe situation (clinical justification) continues. Once the unsafe situation ends, the use of restraint or seclusion must be discontinued."

3. Per CAH policy Restraint & Seclusion /Assessment of the Patient in Restraint and Seclusion states: "1. " ... ...Appropriately qualified RN staff will assess/evaluate the following: Patients placed in restraint or seclusion for violent or self-destructive behavior will be assessed at least every hour by the RN .....2. Assessment means that the patient will be evaluated to determine the patient's response to the restraint or seclusion, and if the patient has any care needs.". However, after being admitted to the ED for alcohol and drug intoxication on 4/28/19 Patient #4 became assaultive and combative with a threat of harm to self and others. The ED provider ordered the application of 4-point restraints which were initiated at 15:45. Per review of "Restraint Assessment" documentation completed by nursing, the 1-hour assessment of Patient #4's response to restraints and evaluation of care needs was not conducted as per policy. At 18:10, after 2 hours and 25 minutes and without hourly assessments the restraints were removed when Patient #4 contracted for safety. On 5/7/19 at 12:40 PM the Informatics Nurse, assisting with review of the Electronic Medical Record (EMR) confirmed the failure of nursing to conduct hourly assessments of the restrained patient. In addition, the Director of Operations for the ED confirmed on 5/7/19 2:00 PM it is his/her expectation documentation and assessments would be conducted as per policy.