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Based on observation and interview, the hospital failed to ensure care in a safe setting for the admitted psychiatric patients. This deficient practice is evidenced by the patients ' rooms not having tamper resistant screws in all areas and having multiple ligature points on the 10 bed adolescent unit, the 18 bed adult unit and the 12 bed geriatric unit.

Findings:

Observations in the hospital on 11/19/17 from 11:00 a.m. until 12:05 p.m. revealed the following safety risks:

4th Floor Adolescent Behavioral Health Unit (5 rooms with 10 beds):
Rooms A-J:
a) 3 hinges on bathroom doors with spaces between them that posed a ligature risk.
b) No safety screws on the hinges of the bathroom doors, sink bases, cubbies for personal items, kick plates of doors, door hardware and the rubber surrounds on the door frames.
c) Box mattress bases in patient rooms where patients were not observed at all times containing handles which could be used as ligature points.
d) Desks with stabilizing bars across the backs of open areas which could be used as ligature points.
e) Curtain rods had spaces that a sheet could have been wrapped around as a ligature point.
f) Bathroom doors with handles that were not flush mounted or of the safety type.


10th Floor East Adult Psychiatric Unit (11 rooms with 18 beds):
Room K
a) No safety screws on the rubber surround on the door frames.
b) 3 hinges on the bathroom door with spaces between them that posed a ligature risk.
c) Box mattress bases where patients were not observed at all times containing handles which could be used as ligature points.

Rooms L and M
a) Exposed elbow pipes at back, top of the toilet.
b) Desks with stabilizing bars across the backs of open areas which could be used as ligature points.
c) No safety screws on the door kick plates or door hardware.

The seclusion room had a 3 hinged door, no safety screws in the door, plumbing exposed on the sink and toilet of adjoining bathroom, hinges on bathroom doors (Patients were allowed to access this area if they needed quiet time without being supervised).

10 West Geri Psych (6 rooms with 12 beds)
Rooms N-Y
a) 3 hinges on the bathroom door with spaces between them that posed a ligature risk.
b) Exposed elbow pipes at back, top of the toilets.
c) Desks with stabilizing bars across the backs of open areas which could be used as ligature points.

Rooms N-U
a) 2 doors with 3 hinges on personal storage cabinets with spaces between them that posed a ligature risk.

In an interview on 1/19/17 at 11:45 a.m. with S3PsychDON, she verified patients could go into the seclusion room and bathroom on the adult psychiatric unit if they needed some alone time and were not continuously monitored. She also verified the above mentioned safety findings in the patients ' rooms.

Based on policy review, record review and interview, the hospital failed to ensure the RN(Registered Nurse) supervised and evaluated the care of each patient. This deficient practice was evidenced by failure of the RN to ensure a competent staff member had documented assessments of circulation and range of motion (in restrained limbs) every 15 minutes for the duration of restraint use for 4 (#1,#3,#4,#5) of 5 (#1-#5) Emergency Department patients reviewed for restraints and failed to ensure the presence of restraints was accurately documented every 15 minutes for 1(Patient #5) of 5 (#1-#5) Emergency Department patients reviewed for restraints.
Findings:
Review of the hospital's policy titled, Seclusion and/or Restraint, issued 9/2016, revealed in part: G. Care of the Person in Seclusion/Restraint. The RN shall reassess the need for seclusion/restraint every hour. 2. Monitoring: A competent staff member shall assess the patient at the initiation of restraint or seclusion and every 15 minutes thereafter. The assessment shall include the following (unless it is inappropriate for the type of seclusion or restraint employed): Signs of any injury associated with applying restraint or seclusion; Nutrition and Hydration; Circulation and Range of Motion (ROM) in the extremities; Vital Signs; Hygiene and Elimination; Physical and Psychological status and comfort; Readiness for discontinuation of restraint or seclusion.


Patient #1
Review of Patient #1's medical record revealed the patient was placed in 4 point restraints (left and right wrist/left and right ankle) in the hospital's ED (Emergency Department) on 1/13/17 from 3:30 p.m. - 5:00 p.m. The patient was restrained due to being an immediate or serious danger to the physical safety of self or others (patient swinging and kicking at staff, cursing and threatening staff).

Review of the Behavior/Seclusion Restraint (Violent) Assessment documentation, dated 1/13/17, revealed no documented evidence that the patient's circulation and ROM (in all 4 extremities where restraints were applied) had been assessed q (every) 15 minutes (as directed in the restraint policy and as indicated on the restraint documentation form) from 3:30 p.m. (restraints initiated) - 5:00 p.m. (restraints removed).

Patient #3
Review of Patient #3's medical record revealed the patient was placed in 4 point restraints (left and right wrist/left and right ankle) in the hospital's ED on 1/12/17 from 6:30 p.m.-7:45 p.m. The patient was restrained due to being an immediate or serious danger to the physical safety of self or others (patient threatened to bite staff on the neck and pushed staff repeatedly).

Review of the Behavior/Seclusion Restraint (Violent) Assessment documentation, dated 1/12/17, revealed no documented evidence that the patient's circulation and ROM (in all 4 extremities where restraints were applied) had been assessed q 15 minutes from 6:30 p.m. (restraints initiated) -7:45 p.m. (restraints removed).

Patient #4
Review of Patient #4's medical record revealed the patient was placed in 4 point restraints (left and right wrist/left and right ankle) in the hospital's ED on 1/16/17 from 3:45 p.m. - 6:00 p.m. The patient was restrained due to being an immediate or serious danger to the physical safety of self or others (patient not cooperative with staff, yelling, aggressive-arrived via ambulance in 4 point restraints).

Review of the Behavior/Seclusion Restraint (Violent) Assessment documentation, dated 1/16/17, revealed no documented evidence that the patient's circulation and ROM (in all 4 extremities where restraints were applied) had been assessed q 15 minutes from 4:30 p.m. - 6:00 p.m. (restraints removed).

Patient #5
Review of Patient #5's medical record revealed the patient was placed in 4 point restraints (left and right wrist/left and right ankle) in the hospital's ED on 1/17/17 from 3:10 a.m.- 7:30 a.m. (according to restraint documentation and ED nurses' note documentation). The patient was restrained due to being an immediate or serious danger to the physical safety of self or others (patient aggressive towards staff, trying to hit them).

Review of the Behavior/Seclusion Restraint (Violent) Assessment documentation, dated 1/17/17, revealed the start time of the application of the restraints was 3:10 a.m. and the end time (discontinuation) was 7:10 a.m. Further review revealed no documented evidence of the presence of the 4 point limb restrains from 6:15 a.m.-7:15 a.m. on the q 15 minute restraint assessment form. Additional review revealed no documented evidence that the patient's circulation and ROM (in all 4 extremities where restraints were applied) had been assessed q 15 minutes from 6:15 a.m.- 7:30 a.m.

Review of Patient #5's ED nurses' notes revealed the following entry:
1/17/17 7:30 a.m.: Restraints removed at 7:30 a.m. Further review of Patient #5's nurses' notes revealed no additional restraint use documentation.

In an interview on 1/20/17 at 3:00 p.m. with S2DirED, she confirmed the presence of limb restraints (location), circulation, and ROM of all extremities where restraints were applied should have been assessed and documented q 15 minutes while the patient was in restraints. She indicated if the form directed staff to perform those assessments q15 minutes then it was her expectation that they would have been performed q 15 minutes.