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Based on 1 of 3 records reviewed from the restraint/seclusion log (patients #16) the hospital failed to ensure that restraints were not utilized as a means of staff convenience and/or failed to ensure that restraints were only imposed to ensure the immediate physical safety of the patient, a staff member, or others.

Patient #16 is a 38 year old female who presented to the ED stating that she was an alcoholic and was in the ED last week. The patient stated she could not get sober and is having custody issues with her kids. The patient stated she had a plan "but couldn't bring herself to hit another car." The patient alcohol level was high at 204 on admission and six hours later was 51.

The medical record revealed that patient #16 was placed into restraints on 2/15/10 at 6:30pm, after she ran down the hallway and was stopped at the ambulance doors. Upon the nursing staff trying to escort the patient back to her room the patient became combative and was carried back to the room. Patient screaming she wants to leave. The patient was placed in 4 point restraints and medicated. From 6:30pm to 8:08pm, patient #1 remained in restraints even though the record revealed she was calm and cooperative. There was no documentation regarding specific behaviors justifying the restraints. Under section B the initial evaluation by the physician, behavior leading to restraint/seclusion, the physician wrote wanted to elope, agitation, which does not indicate that the patient had violent or self destructive behaviors . It was determined that staff maintained patient #16 in restraints without sufficient clinical justification.

Based on review of 1 of 3 medical records selected from the restraint/seclusion log, the hospital failed to ensure that seclusion was used only for the management of violent or self destructive behavior.

Patient #17 is a 15 year old male found unresponsive by his sister. The patient was awake upon arrival of EMS. The patient walked to the ambulance. The patient stated he took 8 Xanax and 5 Oxycodone at 1:00pm on 4/12/10 to "get high." The patient denied suicidal and homicidal ideation and was having episodes of bradycardia. The patient was admitted to Upper Chesapeake Medical Center on 4/12/10 at 5:47pm.

The medical record revealed that patient #17 became angry stating "I'm getting the hell out of here and you can't stop me." The record revealed that the patient was told that he needed to stay to make sure the medication he took was out of his system. Security and the charge nurse were called and the patient moved to room 21 to decrease stimuli and for close observation. The medical record revealed that at 11:00 pm the patient was verbally abusive to staff. The patient stated "I'm going to leave." The ED physician was notified and an order was written to lock door on quiet room for behavioral purposes until patient is calm and cooperative. The patient was not offered less restrictive choices. Under section B titled Behavior leading to Restraint/Seclusion was written agitated, verbally abusive to staff, and flight risk. On 4/13/10 12:30am, it was documented that patient #17 was screaming and cursing. At 1:53am the patient was sitting calmly on the mattress and finally at 2:00am the door was unlocked and the patient placed on 1:1 observation. The observation form for monitoring the patient had the patient asleep from 1:30am to 2:00am.

The patient did indeed present a risk to himself due to the overdose on medication that required observation to ensure patient #17 was medically stable but again the patient had not been offered other least restrictive interventions beyond movement to a room to reduce stimuli. It was substantiated that staff maintained patient #17 in seclusion without sufficient clinical justification when they used seclusion to prevent the patient from leaving the ED.

Based on 2 of 3 medical records selected from the restraint/seclusion log, the hospital failed to ensure that other less restrictive interventions were tried or documented.

Patient #16 is a 38 year old female who presented to the ED stating that she was an alcoholic and was in the ED last week. The patient stated she could not get sober and is having custody issues with her kids. The patient stated she had a plan "but couldn't bring herself to hit another car." The patient alcohol level was high at 204 on admission and six hours later was 51. Patient #16 was described as agitated without any specific behaviors and wanting to elope. Section A of the Restraint/Seclusion for the Management of Violent or Self-Destructive Behavior Documentation Flowsheet, under the less restrictive alternatives attempted the area was blank nor did the nursing notes indicate any less restrictive interventions attempted by the staff prior to restraint.

Patient #17 is a 15 year old male found unresponsive by his sister. The patient was awake upon arrival of EMS. The patient walked to the ambulance. The patient stated he took 8 Xanax and 5 Oxycodone at 1:00pm on 4/12/10 to "get high." The patient denied suicidal and homicidal ideation and was having episodes of bradycardia. The patient was admitted to Upper Chesapeake Medical Center on 4/12/10 at 5:47pm. Patient #17 was described as wanting to leave the ED, angry, moved to room 21 to decrease stimuli, and verbally abusive to staff. After he stated he was going to leave, the physician was notified and an order written to lock door of quiet room until the patient was calm and cooperative. The hospital provided a sitter outside the seclusion room door for 1:1 observation through the window. The only documented less restrictive alternative used by the staff was to move the patient to a room to decrease stimuli.

Based on 2 of 3 medical records reviewed, the hospital failed to ensure restraint/seclusion usage was discontinued at the earliest possible time.

During the on-site survey 3 medical records were selected from the restraint/seclusion log. Based on review of the records, 2 of 3 patients remained in restraint/seclusion after they ceased to be a danger to self or others.

Patient #16 is a 38 year old female who presented to the ED stating that she was an alcoholic and was in the ED last week. The patient stated she could not get sober and is having custody issues with her kids. The patient stated she had a plan "but couldn't bring herself to hit another car." The patient alcohol level was high at 204 on admission and six hours later was 51. The medical record revealed that patient #16 was placed into restraints on 2/15/10 at 6:30 pm, after she ran down the hallway and was stopped at the ambulance doors. Upon the nursing staff trying to escort the patient back to her room the patient became combative and was carried back to the room. Patient screaming she wants to leave. The patient was placed in 4 point restraints and medicated. From 6:30 pm to 8:08 pm, patient #1 remained in restraints even though the record revealed she was calm and cooperative. At 7:06 pm the patient was described as alert and oriented x3 and much more calm. At 7:17 pm the patient was described as calm and cooperative but the physician ordered the patient to remain in restraints, so the patient remained in 4 point restraint. At 8:00 pm the patient remained calm, cooperative and agreeable but instead of discontinuing the restraints the staff took out the left arm and the right leg. It wasn't until 8:08 pm that the patient was finally released from restraints although she had met the criteria for release 51 minutes earlier.

Patient #17 is a 15 year old male found unresponsive by his sister. The patient was awake upon arrival of EMS. The patient walked to the ambulance. The patient stated he took 8 Xanax and 5 Oxycodone at 1:00pm on 4/12/10 to "get high." The patient denied suicidal and homicidal ideation and was having episodes of bradycardia. The patient was admitted to Upper Chesapeake Medical Center on 4/12/10 at 5:47 pm. Patient #17 was described as wanting to leave the ED, angry, moved to room 21 to decrease stimuli, and verbally abusive to staff. After he stated he was going to leave, the physician was notified and an order written to lock door of quiet room until the patient was calm and cooperative. The hospital provided a sitter outside the seclusion room door for 1:1 observation through the window. The patient was placed in lock door seclusion at 11:30 pm per the medical record. He was described screaming and cursing at 12:20 am on 4/13/10. By one hour and 33 minutes later the patient was described as sitting calmly on the mattress and the observation documented the patient asleep. Again, the patient was re-assessed at 2:00 am found to be resting on the mattress and the door unlocked. The patient remained on 1:1 observation.

Based on 2 of 3 medical records selected from the hospital restraint/seclusion log, the hospital failed to ensure that restraint/seclusion documentation was complete as evidenced by:

During the on-site survey, 3 medical records were selected from the hospital restraint/seclusion log for review. In 2 out of the 3 medical records (patient #16) on 2/15/10 at 6:30pm section A of the Restraint/Seclusion for the Management of Violent or Self-Destructive Behavior Documentation Flowsheet was blank. This section of the form includes reasons and behaviors leading to restraint/seclusion, with a list of 9 less restrictive alternatives attempted and space for the team members participating in the initial restraint/seclusion. The form is completed by the RN. The close observation lacks space to document specific behaviors by the staff monitoring the patient while in restraint or seclusion.

Patient #17 on the Restraint/Seclusion Initial Order form section D re-evaluation, the physician documents the criteria for release, efficacy of the treatment plan, and efforts to help the patient regain control was left blank. Again the observation log lacks space to write specific behavior for the staff monitoring the patient.