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Based on interviews, it was determined that the Hospital failed to ensure that the least
restrictive intervention was utilized prior to the application of restraints for one (Patient #1) of 10 patient's medical records reviewed.

Findings include:

Background information:

1) It was alleged that Patient #1 (Pt #1) received poor care in the Emergency Department because a CT scan was not ordered after Pt #1, who was psychotic and left alone in a room, threw him/herself to the floor twice, hitting his/her head on a cement floor. RN#2's first request to provide a 1:1 sitter in the room to keep Patient #1 safe was refused due to lack of staff and Pt #1 was placed in restraints. Later in the day, the Charge Nurse directed the 1:1 sitter to allow Pt #1 was to use the bathroom unattended and Pt. #1 again, threw him/herself to the floor

2) Staff Registered Nurse #1 (RN #1) was interviewed in person on 11/7/11 at 10:15 AM. RN #1 said the nurse assigned to provide Patient #1's care (RN #2) was very concerned about Patient #1's safety because, according to her report, Patient #1 had thrown him/herself forcibly to the floor twice, without attempting to break his/her fall and hit his/her head on the cement floor. It appeared Patient #1 was engaged in self-injurious behavior. RN #2 determined that a 1:1 sitter stationed in the room was required for Patient #1's safety. RN #1 said RN #2 asked her to call the Charge Nurse about obtaining a 1:1 sitter for Patient #1. RN #1 said she spoke with the Charge Nurse and was told there was not enough staff to provided a 1:1 sitter in Patient #1's room. RN #1 said RN #2 had to obtain an order to place Patient #1 in restraints to keep him/her from attempting self injurious behaviors.

3) The Nurse Manager of the ED (Manager) was interviewed in person on 11/7/11 at 11:45 A.M.. The Manager said the incident was brought to her attention and reviewed. The Manager said the review identified that RN #2 appropriately advocated for Patient #1 by requesting a 1:1 sitter. At the time of the request, staffing resources were not available in the ED. The Manager said the Hospital's chain of command should have been, but was not utilized, by any of the nursing staff involved to access additional resources.

Review of documentation indicated that the Hospital failed to ensure that restraint and seclusion were utilized in accordance with a physician's order in 5 (Patients #1, #3, #4, #6 and #8) out of 10 patient medical records reviewed.

Findings include:

1) Review of the Hospital policy which addressed restraint and seclusion indicated that as soon as possible after the initiation of restraint or seclusion, the registered nurse shall consult with a responsible physician about the patient's physical and psychological status and obtain an order.

2.) Review of physician orders in Patient #1's medical record indicated restraints/seclusion orders were also written on 9/17/11 at 7:00 AM, however, the type of restraint and/or seclusion ordered, reason for the restraint/seclusion and alternatives attempted prior to ordering the restraint and seclusion, were not indicated.

Review of the restraint/seclusion orders written on 9/17/11 at 11:00 A.M., 3:00 PM and 7:00 P.M. and 9/19/11 at 7:00 A.M., 11:00 AM, 3:00 PM and 7:00 PM, were signed, dated and timed, but they did not include the reason for restraint/seclusion or if the order was being renewed or discontinued.

Restraint and seclusion orders were also written on 9/17/11 at 11:00 P.M., on 9/18/11, at 3:00 A.M., 7:00 A.M., 11:00 A.M., 3:00 P.M., 7:00 P.M., 11:00 P.M. on 9/19/11 at 3:00 P.M., 11:00 P.M. and on 9/20/11 at 7:00 A.M., but none of these orders specifically identified what was being ordered, restraint or seclusion.

Review of 9/18/11 nursing documentation indicated that Patient #1 was placed in bilateral wrist restraints at 9:20 A.M. Review of 9/18/11 physician orders indicated that an order was not written for the application of the bilateral wrist restraints.

3.) Review of Patient #3's medical record indicated that an order was written on 10/13/11 at 5:30 P.M. by the Physician to place Patient #3 in soft wrist restraints, 4 point restraints, chemical restraint and in seclusion. The Physician checked off each item on the checklist, signed and dated the sheet. Patient #3 was placed in seclusion. Documentation did not indicate if any of the other ordered restraints were utilized.

Review of the restraint/seclusion orders indicated that an order was signed on 10/13/11 at 9:30 P.M. However, the order did not specify if the order was for renewal or discontinuance of the previous 5:30 P.M. order.

4.) Review of Patient #4's medical record indicated that a physician had signed the Hospital's Restraint and Seclusion order form on 9/19/11 at 6:00 P.M. However, the order did not indicate what was ordered, restraint or seclusion. Additional restraint/seclusion orders were also signed on 9/19/11 at 11:00 P.M., 9/20/11 at 2:00 A.M., 6:00 A.M. 10:00 A.M., 2:00 P.M., 6:00 P.M., and 10:00 P.M. and 9/21/11 at 2:00 A.M., however, these orders also did not specify what was ordered, restraint or seclusion, and in some cases, if the order was to renew or discontinue the restraint/seclusion, or why the order was necessary.

Review of 9/19/11, 11:15 P.M. through 9/20/11, 9:33 A.M. nursing documentation indicated that during the time of the unspecified restraint/seclusion order was in effect, Patient #4 was in the hallway because there was no sitter available. Patient #4 remained in the hallway and was not moved into a room until 9/20/11 at 9:33 A.M..

5.) Review of Patient #6's medical record indicated that on 9.18/11 at 2:00 P.M., a physician ordered Patient #6 to be placed in seclusion. Two additional orders on the Restraint and Seclusion order form, on 9/18/11 at 6:00 P.M. and at 10:00 P.M., did not indicate if the order was renewed or discontinued or why, if renewal had been ordered, it was still necessary.

6.) Review of Patient #8's medical record indicated that an order to place Patient #8 in seclusion was signed on 10/9/11 at 4:00 P.M. However, additional orders entered on the Hospital's restraints/seclusion form, on 10/9/11 at 8:00 P.M., on 10/10/11 at noon and 4:00 P.M., and on 10/11/11 at 8:00 A.M., 4:00 P.M. and 8:00 P.M. did not indicate if the order was renewed or discontinued.

Based on review of documentation and interviews, it was determined that the Hospital failed to ensure that a written incident report was consistently completed by staff members after the occurrence of a patient event.

Findings include:

1) The Hospital policy which addressed incident reporting was reviewed. The policy stated Hospital employees are required to complete an Occurrence Report for any patient, employee or visitor who, while on Hospital premises, within Hospital jurisdiction or on Hospital business, is involved in an event that has caused or has the potential to cause personal injury or loss/damage to personal property. All occurrences must be immediately reported verbally to your line manager and then on-line using the incident report data base.

2) Review of Patient #1's medical record indicated that Patient #1 on 9/18/11 at at 6:45 P.M., while in the bathroom alone, threw him/herself back into a wall hitting his/her head.

Review of the Hospital's incident file indicated that there was no occurrence report completed related to Patient #1's throwing him/herself into a wall and hitting his/her head on 9/18/11 at 6:45 P.M.

3) Nursing Assistant #2 (NA #2), who had been assigned to provide 1:1 observation of Patient #1 on 9/18/11, was interviewed in person on on 11/7/11 at 2:15 P.M. with the Risk Manager present at his request. NA #2 said that when Patient #1 had banged his/her head on the bathroom wall, he told the nurse about the occurrence, but he had not made out an incident report as required per hospital policy.

Based on review of documentation and interviews, it was determined that the Hospital failed to ensure there was documentation regarding education provided to nursing staff, after it had been identified that Hospital procedures had not been followed in providing care to Patient #1.

Findings include:

1) The Nurse Manager of the ED (Manager) was interviewed in person on 11/7/11 at 11:45 A.M.. The Manager said the incident involving Patient #1 regarding the request for a 1:1 sitter which was refused was investigated. The Manager said the investigation identified that RN #2 appropriately advocated for Patient #1 by requesting a 1:1 sitter. At the time of the request, staff resources were not available in the ED. The Manager said the Hospital's chain of command should have been, but was not utilized, by any of the nursing staff involved, to access additional resources. The Manager said that failure of nursing staff following the chain of command was discussed at the nurse leadership meetings and ED nursing staff were reminded to follow chain of command while she was rounding in the ED.

However, the Manager said there were no minutes recorded from the leadership meeting, nor did the Manager record attendance at any of the discussions held during rounds in the ED.