HospitalInspections.org

Based on medical record review, staff interview, and review of facility documentation, it was determined that the facility failed to ensure that safe patient care is provided in accordance with facility policy.

Findings include:

1.) The facility failed to ensure that an order for restraints for violent or self-destructive behavior in a 9-year-old patient is renewed every two hours. (Cross Reference to Tag 0171)

2.) The facility failed to ensure that all security staff are able to demonstrate competency when applying restraints. (Cross Reference to Tag 0196)

Based on medical record review, staff interview, and review of facility policy, it was determined that the facility failed to ensure that an order for restraints for violent or self-destructive behavior in a 9-year-old patient is renewed every two hours.

Findings include:

Facility policy titled, "Restraints" (last revised 12/22) states, "... Order renewal: Renewal orders for violent restraints within the 24 hours 1. May be obtained by telephone 2. Time frames for telephone orders: ...b. Children ages 9-17: every 2 [hours]...."

On 8/7/23 at 1:06 PM, a review of Patient (P)1's medical record revealed the following:

On 6/18/23 at 11:53 AM, P1, a 9-year-old patient, arrived in the Emergency Department (ED) with an arrival complaint of "violent outburst," for a psychiatric evaluation. At 17:45 [5:45 PM], Staff (S)14 (Registered Nurse) documented that the patient was placed in restraints after becoming violent. At 17:50 [5:50 PM], S15 (ED Physician) placed an order for "Restraints Violent or Self-destructive Adolescent (age 9 to 17)" with a frequency of "Routine Continuous x 2 hours 06/18/23 1750 - 2 hours." Review of the "Restraint Summary" flowsheet documentation by nursing staff revealed that P1 remained in restraints until 23:15 [11:15 PM], five hours and 25 minutes.

There was no documentation in the medical record that the order for restraints was renewed at any point during the five hour and twenty-five minutes P1 was in restraints. This finding was confirmed with S1, S2, and S3 upon discovery.

Based on the review of one of four medical record of pediatric patients in restraints (Patient (P)1), staff interview, and review of facility documents, it was determined that the facility failed to ensure that restraints are applied by trained staff in accordance with facility policy.

Findings include:

Facility policy titled, "Restraints" (last revised 12/22) states, "...VI. Who may perform?: A. RN competencied in the safe application and use of restraints. VII. Who may assist?: A. RN, LPN, PCT, Security officer, Observer, and staff trained in the safe application and use of restraints. ..."

On 8/7/23 at 11:39 AM, a tour of the Pediatric Emergency Department (ED) was conducted with Staff (S)1 (Assistant Vice President of Quality), S2 (Risk Safety Manager), S3 (Director Patient Safety), S9 (Assistant Nurse Manager, Emergency Department, Pediatrics), and S10 (Emergency Department Director, Pediatrics). Upon interview, S10 stated that a registered nurse (RN) or a security officer can apply restraints, but that if a security officer applies restraints, the RN checks the application.

On 8/7/23 at 1:06 PM, a review of Patient (P)1's medical record revealed the following:

On 6/18/23 at 11:53 AM, P1, a 9-year-old patient, arrived in the Emergency Department (ED) with an arrival complaint of "violent outburst," for a psychiatric evaluation. At 17:45 [5:45 PM], S14 (Registered Nurse) documented that the patient was placed in restraints after becoming violent, and that the patient was "physically held safely until security arrived to restrain [him/her]." At 18:56 [6:56 PM], S14 documented, "Pt [patient] escaped from right wrist whil [sic] I was with another pt [patient]. Security at bedside with patient reapplying restraint." At 20:10 [8:10 PM], S16 (RN) documented that P1 pulled out of the left wrist restraint, and that the left wrist restraint was reapplied by security. At 23:15 [11:15 PM], S16 documented discontinuation of the restraints. On 6/19/23 at 9:15 AM, S17 (RN) documented that the patient became aggressive, did not respond to verbal de-escalation, and security and the ED physician was called to the bedside when the patient was placed in 4 point restraints by security staff.

On 8/7/22, S11 (ED Pediatric Nurse Educator) provided documentation that all Pediatric ED RN's received current restraint education and demonstrated competency in restraint application. At 3:17 PM, S4 (Chief of Security) stated during an interview that all security officers receive restraint education as part of an on-boarding process and complete a yearly competency.

On 8/8/22 at 10:06 AM, following the review of the Security/Safety Event reports, a request was made for documentation that the security officers (S18 through S23, and S29) involved in the application of P1's restraints had received restraint education and demonstrated competency. At 1:10 PM, S1 provided documentation that S18, S22 and S29 had completed online restraint education but was unable to provide documentation that hands-on competencies had been completed. At 1:22 PM, an interview with S24 (Security Lieutenant) revealed that up until June 2023, security officers were trained in therapeutic holds only, and beginning in June, two officers at this campus were certified to place restraints. At 1:50 PM, S1 provided documentation that two security officers (S21 and S25) completed "Security - Restraint Validation Train the Trainer" education on 6/19/23. S1 stated that the two security officers and the Advanced Nurse Clinicians then began the process of educating all the security officers.

At 2:45 PM, S1 provided a list of the facility's 31 security guards and documented the eight security officers who had completed restraint hands-on competency education. S1 was unable to provide completed competency checklists for the eight security officers and stated that as the security officers are being trained, they are taking their own competency checklists with them. The facility was unable to provide documentation that security officers have demonstrated competency in restraint application.