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Based on observation, interview, and document review, the facility failed to discontinue restraints at the earliest possible time on the pediatric unit for 1 of 10 patients (P1) reviewed for restraints. This resulted in P1 remaining in locked 2-point restraints for 9 days despite documented times of calm and cooperative behavior. As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.12.

A condition-level deficiency was issued.

Please see A-0174.

Based on observation, interview, and document review, the facility failed to discontinue restraints at the earliest possible time on the pediatric unit for 1 of 10 patients (P1) reviewed for restraints. This resulted in P1 remaining in locked 2-point restraints for 9 days. As a result, the hospital was found out of compliance with the Condition of Participation Patient Rights at 42 CFR 482.12. This failure resulted in an Immediate Jeopardy (IJ).

The IJ began on 3/12/24 when facility staff failed to remove locked restraints from P1 despite documented times of calm and cooperative behavior. The Chief Executive Officer (CEO), Chief Nurse Executive (CNE), Vice President of Performance Improvement and Safety, Accreditation Program Manager, Service Line Critical Care Senior Director, Accreditation Program Specialist, Pediatrics Manager, Pediatric Medical Director, and Pediatrics Physician Chair were notified of the IJ findings on 3/22/24 at 10:23 a.m. The IJ was removed on 3/25/24 at 1:15 p.m. after verification of an acceptable removal plan, but a condition level deficiency was issued.

Findings include:

P1's admission record indicated P1 was admitted to the hospital on 2/15/24 with diagnoses that included autism spectrum disorder, fetal alcohol syndrome, major depressive disorder, and schizophrenia.

P1's medical record indicated on 3/12/24, P1 was placed in 4-point locking restraints after punching a staff member and breaking a window with his foot.

P1's risk assessment by psychologist on 3/13/24 at 4:50 p.m. indicated P1 stated he would not hurt anyone if taken off restraints. The assessment indicated the patient did not appear or show any indication of being in imminent risk to himself or other people. This assessment was shared with the pediatric physician, who is responsible for the overall care of P1 and declined to release P1 from restraints.

3/14/24 1:38 p.m. pediatrician (MD-A) note indicated P1 contracted to not harm property or others. The note also indicated the facility could not ensure the safety of the infants and children on this medical unit where P1 resided. without additional staffing resources (a mental health worker as a 1:1 and a security guard). The above information was reviewed in staff care conference with care coordinator, social worker, nursing, child life, ethics and peds medical team.

3/15/24 7:02 a.m. MD-A note indicated P1 continued in 2-point restraints due to high risk of destruction, harm to self, and harm to others.

3/15/24 9:30 a.m. nursing note indicated patient was understanding, apologetic, laughing and singing.

3/15/24 2:09 p.m. psychologist note indicated P1 denied any interest or plan to hurt another person, denied hallucinations and was calm.

3/17/24 5:06 p.m. MD-A note indicated P1 complained of left arm pain from the restraints.

3/18/24 12:30 p.m. nursing note indicated P1 was hearing voices that were frightening and requested as needed antianxiety medication. P1 was redirectable with conversation and music.

3/18/24 5:33 p.m. physical therapy note indicated restraints were removed with 2 security guards present in the therapy gym. The patient was in good mood and cooperative with therapy. Restraints were reapplied following therapy.

3/19/24 Psychologist note indicated P1 was pleasant, engaged and calm. "Violent restraints incur risk of traumatizing an individual, especially if those individuals are a vulnerable person and people with a trauma history, such as this patient".

P1's Restraint Flow Sheets indicated he was in either 4-point or 2-point restraints continuously from 3/12/24 through 3/21/24. P1 was released from continuous restraints only to toilet, to ambulate or to attend therapy.

On 3/19/24 at 3:15 p.m., P1 was observed lying on his back in his bed with locked restraints on his left wrist and right ankle. P1 was interviewed and stated the reason the restraints had been applied. He did not know what he needed to do to have the restraints removed. He stated he hadn't "done anything bad lately".

On 3/20/24 at 2:00 p.m., psychologist was interviewed and stated he was present with P1 when the restraint order was renewed on 3/13/24. P1 was calm and denied intent to hurt self or others, but the restraints were renewed and continued. P1 repeatedly asked to have restraints removed. Psychologist does not have ordering/discontinuing privileges. Psychologist has provided de-escalation techniques and offered to remain on the unit while P1 restraints were removed. P1 remained in restraints.

On 3/20/24 at 2:38 p.m., MD-A stated P1 needs to be compliant with instruction and demonstrate safety for the restraints to be removed. P1 is largely doing those requirements. The facility does not have the resources to keep him and others safe after removal. "I don't want him in violent restraints, but I can't think of another way to keep him safe. We are not the right place for his healing."

On 3/21/24 at 8:33 a.m., social worker (SW)-A stated she is working on placement an inpatient pediatric psych unit. P1 has been denied due to aggression and acuity and identified P1 is calm and appropriate during the visits.

On 3/21/24 at 10:23 a.m., nurse manager (NM) of the pediatric unit stated the pediatric department had asked for additional resources to assist with the safety on the unit during the initial 48 hours following the discontinuation of restraints for P1. Requests included but not limited to security present on the pediatric unit, 1 to 1 mental health workers, or moving the patient to a different secure unit. The requests were declined citing limited resources.

The Hennepin Healthcare System Restraint and Seclusion policy dated 3/9/2021 instructs discontinuation of restraint and seclusion should occur as soon as possible, based on an individualized patient assessment and reevaluation, when the observed behaviors have decreased in severity or no longer present and the patient has met the discontinuation criteria regardless of the scheduled expiration of the order.

The IJ was removed on 3/25/24 at 1:15 p.m. after the following actions were completed: current restraint and Seclusion policy was reviewed with no revisions needed. A new supporting document, Violent Restraint Process in Pediatrics was added to the Restraint and Seclusion policy. The new supporting document outlined the purpose of ensuring the least restrictive interventions for the least amount of time and is specific to the pediatric' unit's restraint use. Online education on the new supporting document, violent restraints, ensuring the least restrictive restraint use for the least amount of time and utilization of the chain of command when inappropriate use of behavioral restraints id identified was provided to pediatric unit nurses, physicians, and health care workers. Each team member will complete this education during their first shift working on the pediatric unit. The Violent Restraint Patient Flow Meeting Standard work was created to provide oversight to patient in violent restraints. The standard work form will be filled out daily and presented at the daily patient flow meeting for each patient in violent restraints. All patients in violent restraints will be reviewed for validation of patient behaviors warranting continued use of violent restraints, reduction strategies attempted, and any resources needed. This was verified through staff interview and document review.