HospitalInspections.org
Bringing transparency to federal inspections
PRESENCE SAINTS MARY AND ELIZABETH MEDICAL CENTER
PATIENT RIGHTS: RESTRAINT OR SECLUSION
Tag No.: A0168
Based on document review and interview, it was determined, that for 2 of 9 patients (Pts. #2 & #4) placed in violent restraints, the Hospital failed to ensure that the use of restraint was in accordance with the order of a physician or other licensed practitioner, authorized to order restraint by hospital policy in accordance with State law.
Findings include:
1. Hospital policy titled, "Restraint and Seclusion Management Policy," effective 9/19/2022, was reviewed. The policy required, "VII. Violent, Self Destructive Restraint and Seclusion... B. Violent, Self Destructive Restraint Order Requirements: 1. Every order for violent or self-destructive restraint must be in writing by an Authorized Clinician and include... b. The type of restraints..."
2. On 10/31/2022, Pt. #2's clinical record was reviewed. Pt. #2 was admitted to the Hospital on 10/27/2022, with a diagnosis of schizoaffective disorder (psychotic and mood disorders). Pt. #2's nursing notes dated 10/28/2022 at 10:00 AM, included, "Patient placed in 4 point (4 extremities) restraints for escalating behavior and threatening and attempting to attack staff... Order for restraints obtained..." However, a written order for restraints was not found in Pt. #2's clinical record.
3. On 10/31/2022, Pt. #4's clinical record was reviewed. Pt. #4 was admitted to the Hospital on 10/21/2022, with diagnoses of paranoia (distrust of others) and schizophrenia (inability to think, feel, and/or behave clearly). Pt. #4's nursing notes dated 10/27/2022 at 2:00 AM, included, "Patient... being combative and aggressive towards staff and other patients prompted the need for restraints." A written order for restraints dated 10/27/2022 at 2:01 AM, included, "restraint type: 4 siderails". The order was not for 4 point/violent restraints. Pt. #4's 15 minute restraint safety checks included that Pt. #4 observed every 15 minutes in 4 point restraints on 10/27/2022 from 1:30 AM until released at 5:30 AM.
4. On 10/31/2022 at 10:45 AM, an interview was conduced with the 15th Floor Adult Female Behavioral Health Unit Nurse Manager (E #1). E #1 stated that a restraint order for Pt. #2 was written, but could not be found. E #1 stated that the restraint order for Pt. #4 was written by a Family Doctor, not a staff Psychiatrist, and should have included 4 point restraints.