HospitalInspections.org

Based on record reviews, and interviews, the facility failed to protect a patient's right to care in a safe environment when, (7) seven out of (11) eleven patient's medical records, chosen, reviewed, and identified by the facility as having been restrained while at the facility, did not have a physician's order for the use of the restraint and the patient did not receive the one-hour face to face medical provider assessment, as the facility's policy required. This failure places patients from being inappropriately held against their will and places them at risk for pain, injury, and death. (Patients #3,5,7.8,9, 10, and 11)

Findings include:

Review of the facility provided policy, Patient's Rights (Last Revision, 04/24) reflected, "We adopt and affirm as policy the following rights of patient/clients who receive services from our facilities:
Considerate and Respectful Care
o To receive ethical, high-quality, safe, and professional care without discrimination
o To be free from all forms of abuse and harassment ..."

Review of the facility provided policy, Security Assistance for Aggressive Behavior (last revised 07/20/22) reflected,
"PURPOSE:
To provide and maintain a safe environment for patients, visitors, physicians, employees and staff and to assure a timely response to situations involving an actual or potential physical threat.
POLICY:
A Security Alert will summon additional staff members in an emergency situation in which a patient, visitor or employee becomes unruly and demonstrates the potential to:
A. Inflict physical harm on themselves or others.
B. Damage the hospital's property or the property of others.


Review of the facility provided policy, "Patient Restraint/Seclusion (Effective 7/1/2023) reflected, "APPENDIX D: DEFINITIONS
The definitions of restraint use types are applicable in any setting in the facility and are not driven by diagnosis.

A. Physical restraint: Any manual method or physical or mechanical device, material, or equipment attached or adjacent to the patient's body that he or she cannot easily remove that restricts freedom of movement or normal access to one's body to include immobilization or reduction of the ability of a patient to move his or her arms, legs, body, or head freely is considered a physical restraint. An object may be a restraint by functional definition, which is when an object restricts the patient's movement or access to his or her body. Under this definition, many commonly used facility devices and practices could meet this definition of a restraint (e.g., tucking in sheets very tightly, use of side rails to prevent a patient from voluntarily getting out of bed, holding a patient to prevent movement, pinning of mitts on infants, arm restraints and other wrappings that prevent infants, children and/or adults from removing invasive lines or reopening surgical sites, etc.) ...
E. Physical Holds: The regulation permits the physical holding of a patient for the purpose of conducting routine physical examinations or tests. However, patients do have the right to refuse treatment. This includes the right to refuse physical examinations or tests. Holding a patient in a manner that restricts the patient's movement against the patient's will is considered restraint. This includes holds that some members of the medical community may term "therapeutic holds." Many deaths have occurred while employing these practices. Physically holding a patient during a forced psychotropic medication procedure is considered a restraint. If the patient is in a physical hold,
a second staff person is assigned to observe the patient to ensure safety and the patient's airway is not compromised.

F. Physical Holding for Forced Medications: The application of force to physically hold a
patient, in order to administer a medication against the patient's wishes, is considered restraint.
The patient has a right to be free of restraint and also has a right to refuse medications, unless
a court has ordered medication treatment. A court order for medication treatment only removes the patient's right to refuse the medication. Additionally, in accordance with State law, some patients may be medicated against their will in certain emergency circumstances. However, in both of these circumstances, health care staff is expected to use the least restrictive method of administering the medication to avoid or reduce the use of force, when possible. The use of force in order to medicate a patient, as with other restraint, must have a physician's order prior to the application of the restraint (use of force). If physical holding for forced medication is necessary with a violent patient, the one-hour face-to-face evaluation requirement would also apply. "

During an interview, on afternoon of 05/22/24 in a facility conference room, Staff # Vice President of Quality stated in part, "A restraint is anything that prevents a patient's movements. All restraints require a physician's order. The nurse can order the restraint, in an emergency, and then get the order from the physician. There must be at least two staff present, one for the hold and the other to monitor the hold, to ensure the safety of the patient."

Review of the Patient #3's Behavioral Emergency Response Team (BERT) program performance improvement evaluation form dated, 10/22/23, reflected a physical hold had been checked off as having been performed. A further medical records review reflected, no physician order for the restraint and no one-hour face to face had not been conducted.

Review of the Patient #5's Behavioral Emergency Response Team (BERT) program performance improvement evaluation form dated, 04/23/24, reflected a physical hold had been checked off as having been performed. A further medical records review reflected, no physician order for the restraint and no one-hour face to face had not been conducted.

Review of the Patient #7's Behavioral Emergency Response Team (BERT) program performance improvement evaluation form dated, 04/09/24 at 2:15 pm, reflected a physical hold had been checked off as having been performed. A further medical records review reflected, no physician order for the restraint and no one-hour face to face had not been conducted.

Review of the Patient #8's Behavioral Emergency Response Team (BERT) program performance improvement evaluation form dated, 3/30/24 at 12:00 am, reflected a physical hold had been checked off as having been performed. A further medical records review reflected, no physician order for the restraint and no one-hour face to face had not been conducted.

Review of the Patient #9's Behavioral Emergency Response Team (BERT) program performance improvement evaluation form dated, 03/23/24 at 9:39 am to 10:51 am, reflected a physical hold had been checked off as having been performed. The staff documented, "Patient was literally a physical hold from the time I arrived on the unit up until the Bert was called off."
Further medical records review reflected, no physician order for the restraint and no one-hour face to face had not been conducted.

Review of the Patient #10's Behavioral Emergency Response Team (BERT) program performance improvement evaluation forms dated 02/14/24, the first Bert was at 8:00 pm, and a second Bert was at 9:03 pm. A physical hold had been checked off as having been performed for both response visits. Further medical records review reflected, no physician order for the restraint and no one-hour face to face had not been conducted.

Review of the Patient #11's Behavioral Emergency Response Team (BERT) program performance improvement evaluation form dated, 10/06/23 at 1:00 pm, reflected a physical hold had been checked off as having been performed. Further medical records review reflected, no physician order for the restraint and no one-hour face to face had not been conducted.

During the records review on the afternoon of 5/22/24, Staff #12, Director of Behavioral Health, confirmed the missing physician's orders and the missing face-to-face assessments and explained the BERT are specially trained staff that will come to emergency behavioral events, they are not there to do a take-down (bringing the patient to the ground). They try to de-escalate the situation and they document the events.