HospitalInspections.org

Based on review of hospital documents, policies/procedures, medical record review, and staff interview, the hospital failed to implement systems that assured patient's rights related to restraint and seclusion usage were consistently met and to demonstrate that the hospital staff protected and promoted the rights of each patient cared for in the Mental Health Unit (MHU).
On 4-26-10, the hospital administration reported a census of 16 inpatients on the MHU.

This determination was evidenced by:

1. The hospital failed to ensure that restraint or seclusion are only used when less restrictive interventions have been determined to be ineffective to protect the patient, a staff member, or others from harm. (See A-0164, A-0165, A-0184, A-0186)

2 The hospital failed to ensure that staff implemented seclusion in accordance with a written modification to the patient's plan of care. (See A-0166)

3. The hospital failed to ensure that staff consulted the attending physician as soon as possible after staff placed a patient in seclusion. (See A-0170, A-182)

4. The hospital failed to ensure that each order for restraint or seclusion (used for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others) could only be renewed in accordance with the following limits for up to a total of 24 hours:

(A) 4 hours for adults 18 years of age or older;
(B) 2 hours for children and adolescents 9 to 17 years of age; or
(C) 1-hour for children under 9 years of age (See A-171)

5. The hospital failed to ensure that a trained physician, mid-level provider, or Registered Nurse evaluated and documented the physical/psychological impact of interventions within one (1) hour of the application of restraint or seclusion. (See A-178, A-0184)


The cumulative effect of these systemic failures and deficient practices resulted in the hospital's significant inability to ensure that staff understood, and upheld all patients' rights and safeguarded these rights.

Based on review of policies/procedures, medical record review, and staff interview, the hospital failed to ensure that staff consistently documented, in the patient's medical record, the least restrictive intervention or the rationale for not using least restrictive alternatives to restraints/seclusion in 5 of 8 closed medical records. (Patients #1, 4, 5, 6, and 8)

Failure to ensure that staff consistently documented all attempts at less restrictive interventions has the potential to place patients at risk for physical and/or psychological harm and prevents staff from having documentation of interventions that may or may not work with the patient.

On 4/26/10, hospital administration reported a census on the Mental Health Unit of 16 patients.
Findings Include:

1. On 5/5/10 at 12:00 PM, review of hospital policy titled "Restraint or Seclusion " dated May 2007 revealed the following:
Procedure:
A. Assess patient behaviors and effectiveness of alternatives for use of restraints (seclusion) using the decision flow chart (Attachment A and B). Evaluate, try, and document all other interventions and alternatives prior to using restraints (seclusion).

2. Review of 5 of 8 closed seclusion medical records, on 5/5/10, revealed that staff failed to document less restrictive interventions attempted prior to the use of seclusion to control violent or self-destructive behavior.

3. During an interview, on 5/5/10 at 2:30 PM, the Director of the Mental Health Unit, acknowledged that nursing staff failed to document less restrictive alternatives tried prior to placing the patients in seclusion in 5 of 8 closed seclusion records. (Patients #1, 4, 5, 6, and 8)

4. During an interview, on 5/5/10 at 2:30 PM, the Vice President of Patient Care Services acknowledged that nursing staff failed to document less restrictive alternatives attempted prior to placing patients in seclusion in 5 of 8 closed seclusion records. (Patients #1, 4, 5, 6, and 8).

Based on policy/procedure review, medical record review, and staff interview the hospital failed to ensure that staff determine which technique of restraint or seclusion was the least restrictive alternative that would meet the patients' needs and protect the patient, staff, or others from harm in 5 of 8 medical records. (Patients #1, 4, 5, 6, and 8)

Failure to ensure that all MHU staff consistently and completely documented patient seclusion could potentially compromise patient safety and increase the risk of physical and/or psychological harm. On 4/26/10, hospital administrative staff reported a census on the Mental Health Unit of 16 inpatients.
Findings included:

1. Review of hospital policy titled "Restraint or Seclusion", dated May 2007, revealed the following:
Procedure:
A. Assess patient behaviors and effectiveness of alternatives for use of restraints (seclusion) using the decision flow chart (Attachment A and B). Evaluate, try, and document all other interventions and alternatives prior to using restraints (seclusion).

B. Attachment B: Restraint/Seclusion Standards for Emergent Use (flow sheet)
Assess Patient Needs
Consider/Implement Alternatives to Restraint/Seclusion
Do Alternatives Work - No?
Determine least restrictive restraint (based on assessment)

2. Review of closed seclusion medical records, on 5/5/10, revealed that staff failed to document less restrictive interventions attempted prior to the use of seclusion to control violent or self-destructive behavior. Documentation also failed to address specific patient behaviors and the effectiveness of alternatives of any/all alternatives attempted. (Patients #1, 4, 5, 6, and 8)

3. During an interview, on 5/5/10 at 2:30 PM, the Director of the Mental Health Unit, acknowledged that nursing staff failed to document less restrictive alternatives tried prior to placing the patients in seclusion in 5 of 8 closed seclusion records. (Patients #1, 4, 5, 6, and 8)

4. During an interview, on 5/5/10 at 2:30 PM, the Vice President of Patient Care Services acknowledged that nursing staff failed to document less restrictive alternatives attempted prior to placing patients in seclusion in 5 of 8 closed seclusion records (Patients #1, 4, 5, 6, and 8).

Based on policy/procedure review, closed medical record review, and staff interviews, the hospital failed to ensure all nursing staff update patient care plans following application of seclusion and/or restraints in 2 of 8 closed seclusion medical records. (Patients #1 and 5)

Failure to update a patient care plan, after application of seclusion or restraint, may results in the failure to identify patient problems, interventions to address those problems and/or desired outcomes, and failure to communicate or coordinate patient care.

On 4/26/10, hospital administration reported a census on the Mental Health Unit of 16 patients.
Findings included:

1. Patient Care policy/procedure titled "Restraint or Seclusion", dated July 2007, states:
Policy:
...I. "The RN shall initiate an individualized plan of care for each patient requiring restraint. The plan of care shall be reviewed and modified to reflect a loop of assessment, intervention, evaluation, and re-evaluation... The plan of care will be evaluated a minimum of every shift."

2. Review of the closed patient medical record for Patient's #1 and #5 revealed the patients placed in seclusion during hospitalization. The care plan lacked evidence of updates to reflect the use of seclusion as part of the treatment for these patients.

3. During an interview on 4/26/10 at 3:00 PM, the Director of the Mental Health Unit acknowledged that the hospital policy titled "Restraint or Seclusion" did not address an update of the patient's care plan when MHU staff place patients in seclusion to control violent or self-destructive behavior.

The Director of the Mental Health Unit also acknowledged that Patient's #1 and #5 medical record lacked evidence that the patients ' care plan was updated after the use of seclusion for the control of violent or self destructive behavior.

Based on policy/procedure review, medical record review, and staff interviews, staff failed to consult with the patient's attending physician, after the application of seclusion, for 8 of 8 closed medical records. (Patient's #1, 2, 3, 4, 5, 6, 7, and 8) The attending physician potentially has information regarding the patient's history that may have a significant impact on the selection of seclusion as an interventions or alternative intervention.

Failure to consult with the attending physician may place patients at risk for psychological harm related to unnecessary restraint/seclusion usage and fail to elicit information that might be relevant in choosing the most appropriate intervention for the patient

On 4/26/10, hospital administrative staff reported a census on the Mental Health Unit of 16 patients.
Findings included:

1. Review of hospital policy titled "Restraint or Seclusion" dated May 2007 revealed the following:
Policy ..."F. An order from a physician or Licensed Independent Provider (LIP), as appropriate per hospital policy, is required for restraint or seclusion use. ... The attending physician or LIP must be consulted as soon a possible if the restraint or seclusion is not ordered by that provider (Attending physician/LIP)."

2. Review of closed seclusion medical records, 5/5/10, revealed that 8 of 8 medical records lacked evidence that MHU staff notified the attending physician when the patients were placed in seclusion for violent or self-destructive behavior (Patient's #1, 2, 3, 4, 5, 6, 7, and 8).

3. During an interview, on 5/5/10 at 2:30 PM, the Director of the Mental Health Unit acknowledged that nursing staff failed to notify and/or failed to document that the attending physician was notified of the patient ' s seclusion for violent or self destructive behavior. (Patient's #1, 2, 3, 4, 5, 6, 7, and 8)

4. During an interview, on 5/5/10 at 2:30 PM, the Vice President of Patient Care Services acknowledged that nursing staff failed to notify and/or failed to document that the attending physician was notified of the patient ' s seclusion for violent or self destructive behavior (Patient's #1, 2, 3, 4, 5, 6, 7, and 8).

Based on policy/procedure review, medical record review, and staff interview, the hospital failed to ensure that physician or mid-level provider's seclusion orders were time limited to four (4) hours for adult patients in seclusion on the Mental Health Unit. Problem identified with 3 of 8 closed medical records reviewed (Patient #1, 3, and 5).

Failure to ensure that all physician/mid-level seclusion orders are time limited has the potential to put patients at risk for prolonged seclusion and possible physical/psychological harm.

On 4/26/10, hospital administrative staff reported a census on the Mental Health Unit of 16 patients.
Findings included:

1. Review of policy/procedure titled, "Restraint or Seclusion", dated May 2007, revealed:
Policy ... #2. Emergent ...d. Each written order for a physical restraint or seclusion is time limited. For adult patients the time will be limited to four hours.

2. Review of closed seclusion medical records lacked documentation of a four-hour time limit for seclusion orders in 3 of 8 closed medical records (Patient #1, 3, and 5).

3. During an interview, on 5/5/10 at 2:30 PM, the Director of the Mental Health Unit acknowledged that the closed medical records for Patient's #1, #3, and #5 lacked evidence of a four-hour time limit for the seclusion orders.


4. During an interview, on 5/5/10 at 2:30 PM, the Vice President of Patient Care Services acknowledged that the closed medical records for Patient's #1, #3, and #5 lacked evidence of a four-hour time limit for the seclusion orders.

Based on policy/procedure review, medical record review, and staff interviews, the hospital failed to ensure that trained staff evaluated the patient face-to-face within 1 hour after staff utilized seclusion to control violent and/or self-destructive behavior in 5 of 8 closed medical records reviewed (Patient's #1, 2, 5, 7, and 8).

Failure to complete or document a face-to-face evaluation within 1 hour after placing a patient in seclusion prevents prompt evaluation of the patient ' s behavior that led to the intervention. The evaluation could determine whether there is a continued need for the intervention, identify factors that may have contributed to the violent or self-destructive behavior, and whether the intervention was appropriate to address the violent or self-destructive behavior.

Findings included:

1. Review of policy/procedure titled "Restraint or Seclusion " , dated May 2007, revealed:
...Policy:
... " Emergent: ... c. The patient must be evaluated within one hour after initiation of restraint by a Registered Nurse or PA (Physician ' s Assistant) who has specific training. This evaluation shall include the patient ' s reaction to the intervention, the patient ' s medical and behavioral condition and the need to continue or terminate the restraint or seclusion ... "

2. Review of closed seclusion medical records, on 5/5/10, revealed that 5 of 8 medical records lacked evidence that trained staff completed a one-hour face-to-face evaluation after they placed the patient in seclusion for violent or self-destructive behavior. (Patient's #1, 2, 5, 7, and 8)

3. During an interview, on 5/5/10 at 2:30 PM, the Director of the Mental Health Unit acknowledged that 5 of 8 medical records lacked evidence that MHU staff completed a one-hour face-to-face evaluation after they placed the patient in seclusion for violent or self-destructive behavior (Patient's #1, 2, 5, 7, and 8).

4. During an interview, on 5/5/10 at 2:30 PM, the Vice President of Patient Care Services acknowledged that 5 of 8 medical records lacked evidence that MHU staff completed a one-hour face-to-face evaluation after they placed the patient in seclusion for violent or self-destructive behavior (Patient's #1, 2, 5, 7, and 8).

Based on policy/procedure review, medical record review, and staff interviews, staff failed to consult with the patient's attending physician, after assessing the patient in the hour face-to-face evaluation, for 3 of 8 closed medical records. (Patient's #3, 4, and 6) The attending physician potentially has information regarding the patient's history that may have a significant impact on the continuation of seclusion.

Failure to consult with the attending physician may place patients at risk for psychological harm related to prolonged restraint/seclusion and failure to elicit information that might be relevant in choosing the most appropriate intervention for the patient

On 4/26/10, hospital administrative staff reported a census on the Mental Health Unit of 16 patients.
Findings included:

1. Review of hospital policy titled "Restraint or Seclusion" dated May 2007, lacked a requirement for the attending physician to be consulted, as soon as possible, after the one hour face to face evaluation.

2. Review of closed seclusion medical records, 5/5/10, revealed that 8 of 8 medical records lacked evidence that the trained staff notified the attending physician after the completion of the one-hour face-to-face evaluation. (Patient's #3, 4, and 6)

3. During an interview, on 5/5/10 at 2:30 PM, the Director of the Mental Health Unit acknowledged the hospital ' s policy lacked a required that required MHU staff to consult the patient's attending physician as soon as possible after the one-hour face-to-face evaluation.


4. During an interview, on 5/5/10 at 2:30 PM, the Vice President of Patient Care Services acknowledged the hospital ' s policy lacked a required that required MHU staff to consult the patient's attending physician as soon as possible after the one-hour face-to-face evaluation.

Based on policy/procedure review, medical record review, and staff interviews, the hospital failed to ensure that trained staff evaluated the patient face-to-face within 1 hour after staff utilized seclusion to control violent and/or self-destructive behavior in 5 of 8 closed medical records reviewed. (Patient's #1, 2, 5, 7, and 8)

Failure to complete or document a fact-to-face evaluation within 1 hour after placing a patient in seclusion prevents prompt evaluation of the patient ' s behavior that led to the intervention. The evaluation could determine whether there is a continued need for the intervention, identify factors that may have contributed to the violent or self-destructive behavior, and whether the intervention was appropriate to address the violent or self-destructive behavior.

Findings included:

1. Review of policy/procedure titled "Restraint or Seclusion " , dated May 2007, revealed:
...Policy:
... " Emergent: ... c. The patient must be evaluated within one hour after initiation of restraint by a Registered Nurse or PA (Physician ' s Assistant) who has specific training. This evaluation shall include the patient ' s reaction to the intervention, the patient ' s medical and behavioral condition and the need to continue or terminate the restraint or seclusion ... "

2. Review of closed seclusion medical records, on 5/5/10, revealed that 5 of 8 medical records lacked evidence that MHU staff completed a one-hour face-to-face evaluation after they placed the patient in seclusion for violent or self-destructive behavior. (Patient's #1, 2, 5, 7, and 8)

3. During an interview, on 5/5/10 at 2:30 PM, the Director of the Mental Health Unit acknowledged that 5 of 8 medical records lacked evidence that MHU staff completed a one-hour face-to-face evaluation after they placed the patient in seclusion for violent or self-destructive behavior. (Patient's #1, 2, 5, 7, and 8)

4. During an interview, on 5/5/10 at 2:30 PM, the Vice President of Patient Care Services acknowledged that 5 of 8 medical records lacked evidence that MHU staff completed a one-hour face-to-face evaluation after they placed the patient in seclusion for violent or self-destructive behavior. (Patient's #1, 2, 5, 7, and 8).

Based on policy/procedure review, medical record review, and staff interview the hospital failed to ensure that staff determined which technique of restraint or seclusion was the least restrictive alternative that would meet the patients' needs and protect the patient, staff, or others from harm in 5 of 8 closed medical records (Patients #1, 4, 5, 6, and 8).

Failure to document the least restive alternatives attempted prior to the seclusion of a patient has the potential to compromise patient safety and cause physical and/or psychological harm.

On 4/26/10, hospital administrative staff reported a census on the Mental Health Unit of 16 patients.
Findings included:

1. On 5/5/10 at 12:00 PM, review of hospital policy titled "Restraint or Seclusion", dated May 2007, revealed:

Procedure:
A. Assess patient behaviors and effectiveness of alternatives for use of restraints (seclusion) using the decision flow chart (Attachment A and B). Evaluate, try, and document all other interventions and alternatives prior to using restraints (seclusion).

B. Attachment B: Restraint/Seclusion Standards for Emergent Use (flow sheet)
Assess Patient Needs
Consider/Implement Alternatives to Restraint/Seclusion
Do Alternatives Work - No?
Determine least restrictive restraint (based on assessment)

2. Review of closed seclusion medical records, on 5/5/10, revealed that staff failed to document less restrictive interventions attempted prior to the use of seclusion to control violent or self-destructive behavior. Documentation also failed to address specific patient behaviors and the effectiveness of alternatives of any/all alternatives attempted. (Patients #1, 4, 5, 6, and 8)

3. During an interview, on 5/5/10 at 2:30 PM, the Director of the Mental Health Unit, acknowledged that nursing staff failed to document less restrictive alternatives tried prior to placing the patients in seclusion in 5 of 8 closed seclusion records. (Patients #1, 4, 5, 6, and 8)

4. During an interview, on 5/5/10 at 2:30 PM, the Vice President of Patient Care Services acknowledged that nursing staff failed to document less restrictive alternatives attempted prior to placing patients in seclusion in 5 of 8 closed seclusion records. (Patients #1, 4, 5, 6, and 8).