HospitalInspections.org

Based on a review of five CODE GREENS (behavioral emergencies), 10 closed medical records, policies and procedures, along with interviews of staff on May 6, 2016, it was determined that the documentation did not support the continuing restraint of one patient for whom a code green was called in the emergency department (ED).

Patient 1 was a middle-aged patient brought to the ED in April, 2016 intoxicated. Patient 1's presenting behavior was described as uncooperative, threatening, and intermittently combative. A code green was called when the patient became combative and the patient was placed in four-point restraints at 9:15 AM. The patient remained in restraints until 3:12 PM. The plan for the patient was to "observe until clinically sober."

According to the nurses' flow sheets, at 10:20 AM, the patient was described as agitated, restless and combative. At 11:00 AM and 12:00 noon and 1 PM, the patient was described as agitated and alert. At 2 PM, the patient was described as alert and cooperative. According to a nurse' s note entered at 12:14 PM, the patient was quoted as threatening and yelling, "release me now."

According to the every fifteen minute restraint observation flow sheet, the nurse aides documented that as of 10:00 AM, the patient was cooperative and/or asleep. Because of this discrepancy in behavioral documentation, it was difficult to say that the patient required restraints until 3:12 PM. The patient was discharged at 7:10 PM.

Based on a review of five CODE GREENS ( behavioral emergencies), 10 closed medical records, policies and procedures, along with interviews of staff on May 6, 2016, it was determined that for one patient in behavioral restraints, the hospital's formal face to face procedure was not followed.

Patient #1 was placed in four point restraints for combative behavior at 9:15 AM. There was a note from the ED physician at 10:32 AM noting that patient was threatening, uncooperative, and intermittently combative and was placed in four point restraints.

According to a review of four other patients who had been in restraints for behavioral emergencies, the hospital had a section of their electronic medical record (EMR) where the four requirements of the face to face were to be documented. This documentation was not found in patient #1's EMR. While the note from the physician at 10:32 AM documented the patient's situation and the medical and behavioral conditions present on admission to the ED at 9:15 AM, it lacked an assessment of the patient's condition at 10:32 AM, the reaction to the interventions and the need to continue or terminate the restraint.

In addition, hospital policy RESTRAINT AND SECLUSION (APC 3, last revised 4-2015) lacked an explanation of the specific required parts of the face to face assessment.