HospitalInspections.org

Based on a review of the hospital "Restraint" policy (revised 9/19/2016), and 2 restraint episodes, it was determined that 1) a disparity was found to exist between appropriate restraint discontinuation criteria, and actual staff practices related to releasing patients #8 and #9, from restraint at the earliest possible time; and 2) hospital restraint policy provides for incremental restraint release though no standard exists to support this practice.

Review of the hospital Restraint policy stated in part, "VI. A. Continuous assessment of behavior for early release is an expectation. As early as possible, the patient is made aware of the rationale for restraint and the release criteria for its discontinuation, i.e. patient are no longer violent or self-destructive. Restraint should be discontinued as soon as the unsafe situation ends ..."

Patient #8 was an intellectually disabled patient who was admitted to the hospital in October 2017. On a day in November, patient #8 was appropriately restrained for self-injurious behaviors and attempts to harm others. Appropriate behavioral criteria for release from restraint was documented as "Pt will cease any aggressive behavior towards staff and cease self-injurious behavior." Nursing restraint documentation revealed an assessment element in part, of "Describe patient's ability to follow directions." The nursing response was documented as, "Unable," and elsewhere as "Limited."

However, under the restraint documentation element of "Describe rationale or behavior for (restraint) continuance:" nursing documented, "Patient is unable to follow simple directions to rest head back on mat and be quiet." Alternately, nursing documented that "Patient was told when he can follow directions restraints will be taken off."

Based on this information, nursing assessed that patient #8 who was developmentally disabled, was unable to follow directions, yet release criterion depended upon patient #8 to follow directions. This criterion shifted appropriate behavioral criterion to an unrealistic, intellectual criterion of being "able to follow directions," and to "Be quiet." Per the nursing assessment, patient #8 could not follow directions at a baseline, and the ability to "be quiet" was not a justification for continuing restraint.

Patient #9 was admitted to the hospital in mid-October 2017. On the day of admission, patient #9 was appropriately placed into 4-point restraint when patient #9 demonstrated aggressive behaviors towards staff including pushing, and non-verbal postures suggesting imminent harm.

Appropriate criteria for release given to patient #9 was, "Patient ceases danger to others." Specific behaviors discussed with patient #1 for discontinuation included, "Patient will be able to use coping skills and follow staff directions." While patient #3 had to cease the dangerous behaviors which required restraint, neither a lack of coping skills nor a failure to follow staff direction justified continued restraint.

Nursing later documented two rationales for why patient #9 was not removed from restraint. These were documented as "Still pulling at restraints," and "Patient refused to cooperate with staff by not answering questions." Neither of the aforementioned rationales justified keeping patient #9 restrained, where pulling on restraints did not necessarily represent dangerousness, and where patient #9 had a right not to respond to staff.

Review of the hospital restraint policy under IX. C. revealed, "After assessing the patient, the RN may determine that the number of restraints should be reduced (for example, 4 point to 3 point) instead of immediately releasing the patient from restraints. This may occur without another order from the physician or NP. The RN shall, during her /his hourly assessments, document justification for continued use of the reduced number of restraints or release the patient from restraints."

Based on this policy element, an RN may continue restraints for any reason without standard, guidance, or accountability to regulatory requirements of release from restraint at the earliest possible time.

In summary, the hospital failed to release patients #8 and #9 at the earliest possible time when staff created a disparity between appropriate initial criterion for release, and later criterion unrelated to imminent dangerousness, and per policy, allowed RN's to incrementally release patients from restraint.