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A. Based on review of Hospital policy, clinical record review, and staff interview, it was determined, that for 4 of 6 clinical records reviewed of patients (Pt. #3, 4, 6, & 7) placed in restraints in the Emergency Department (ED), the Hospital failed to ensure restriction of rights forms were completed and given to the patient and/or his legal representative.

Findings include:

1. Hospital policy No. 20-6780.409.10, titled: "Emergency Department Restraint Justification" was reviewed on 7/20/10 at 2:00 PM. The policy required: "G. Process... 2. Initiation of Restraints... b. Patients who are placed in violent restraints will have a 'Restriction of Rights (MMHD-4) form completed...'"

2. On 7/20/10 between 10:00 AM and 1:30 PM, the clinical records of 6 ED patients (Pts. 1 - 4, 6, & 7), who had been restrained, were reviewed. Four patients (Pt. #3, 4, 6, & 7) lacked documentation that the restriction of rights form was completed and provided to the patient.

3. The Director of ED confirmed this finding during an interview on 7/20/10 at 2:15 PM.

A. Based on review of Hospital policy, clinical record review, and staff interview, it was determined, that for 1 of 6 clinical records reviewed of patients (Pt. #4) placed in restraints in the Emergency Department (ED), the Hospital failed to ensure less restrictive interventions were implemented prior to placement of restraints.

Findings include:

1. Hospital policy No. 20-6780.409.10, titled: "Emergency Department Restraint Justification" was reviewed on 7/20/10 at 2:00 PM. The policy required: "E. Limitations:... 3. Less restrictive measure should be determined to be ineffective prior to the initiation of restraints..."

2. On 7/20/10 at 11:00 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a 58 year old male, seen in the ED on 7/2/10 at 8:44 AM. Triage notes at 1:46 PM, included that Pt. #4 was placed in leather restraints. The Restraint Justification Flowsheet at 2:30 PM, gave the reason for restraints as threatening elopement. However, there was no documentation that any alternative intervention (redirection, one to one, etc.) was initiated prior to application of restraint.

3. The Director of ED confirmed this finding during an interview on 7/20/10 at 2:15 PM.

A. Based on review of Hospital policy, clinical record review, and staff interview, it was determined, that for 6 of 6 clinical records reviewed of patients (Pt. #1 - 4, 6 & 7) placed in restraints in the Emergency Department (ED), the Hospital failed to ensure orders included time limits for restraint usage

Findings include:

1. Hospital policy No. 20-6780.409.10, titled: "Emergency Department Restraint Justification" was reviewed on 7/20/10 at 2:00 PM. The policy required: "F. Orders:... 3. The written order must include all the following... c. Length of time the order is in effect, not to exceed..."

2. On 7/20/10 between 10:00 AM and 1:30 PM, the clinical record of 6 ED patients (Pts. 1 - 4, 6, & 7), who had been restrained, were reviewed. None of the orders included the length of time the order was in effect.

3. The Director of ED confirmed this finding during an interview on 7/20/10 at 2:15 PM.

A. Based on review of Hospital policy, clinical record review, and staff interview, it was determined, that for 1 of 6 clinical records reviewed of patients (Pt. #4) placed in restraints in the Emergency Department (ED), the Hospital failed to ensure restraints were discontinued at the earliest possible time.

Findings include:

1. Hospital policy No. 20-6780.409.10, titled: "Emergency Department Restraint Justification" was reviewed on 7/20/10 at 2:00 PM. The policy required: The use of physical restraint must be limited to the duration of the emergency safety situation regardless of the length of the order..."

2. On 7/20/10 at 11:00 AM, the clinical record of Pt. #4 was reviewed. Pt. #4 was a 58 year old male, seen in the ED on 7/2/10 at 8:44 AM. Triage notes at 1:46 PM, included that Pt. #4 was placed in leather restraints. The Restraint Justification Flowsheet at 2:30 PM, gave the reason for restraints as threatening elopement. The ED Observation Log indicated that Pt. #4 was asleep from 3:00 PM until 5:30 PM, 2 1/2 hours. There was no documentation to indicate that Pt. #4 was reassessed to determine if restraints were still necessary.

3. The Director of ED confirmed this finding during an interview on 7/20/10 at 2:15 PM.