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Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the physical hold was entered in the medical record at the time of the physical hold; failed to ensure the leadership notification was completed following the physical hold; failed to ensure debriefing with the patient and/or patient's family within 24 hours after the physical hold was conducted; and failed to ensure the staff debriefing was conducted within 24 hours after the incident for one of four restraint medical records reviewed (MR8).

Findings include:

Review on March 23, 2017, of the facility policy "Restraints," last reviewed July 25, 2016, revealed "Policy: The medical and hospital staff of Robert Packer Hospital (RPH) is committed to preventing and reducing, the use of restraints while maintaining the patient's safety and dignity. A. Definition A. Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely ... C. Violent/Self Destructive (V/SD) Restraints (also known as Behavioral) are the restriction of patient movement for the management of violent or self-destructive behavior that jeopardizes the immediate physical safety of the patient, a staff member, or others. D. Non-Violent Restraint (Also known as Physical Healing) is all restraint other than V/SD above. ... F. Violent/Self Destructive (V/SD) Restraints (also known as Behavioral Health) A. Requirement for All Setting i. Restraint Order A provider's order is required. If the provider is not available, and in an emergency, a registered nurse, mental health therapist or security guard may initiate restraint in advance of a provider's order and the RN will contact the provider immediately (within a few minutes) for an order and document it within one hour. The provider shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of the restraint to evaluate the patient's medical and behavioral condition and need for restraint. ... iii. Physical hold (or known as 'therapeutic hold') Holding a patient in a manner that restricts his/her movement against their will is considered a restraint. When physical hold is used the procedures as described in section IV (Violent/Self destructive restraints) are followed. ... v. Documentation Type and location of the restraining device(s) shall be documented at least once per every 8 hours and when changed. Rationale for restraint (observed condition/behavior/environmental factors) shall be documented at least once every 8 hours Alternatives to and less restrictive forms of restraint considered by the care giver shall be documented at least every 8 hours. ... B. Additional Requirements for Patients Restrained in the Behavioral Health Unit i. Leadership Notification of Continued or Repeated Restraint Behavioral Health Leadership (Director, Medical Director, Clinical Team Leads or Nursing Supervisor) will receive ongoing notification when changes occur or questions/concerns arise ii. Debriefing - As soon as possible but no longer than 24 hours after the conclusion of each restraint episode, the patient and, if appropriate, the patient's family participate with staff members who were involved in the episode in a debriefing. Staff debriefing to be held following incident; participants to include as many as possible of those staff members involved in or present during incident. Debriefing to be conducted as soon as possible following incident; but no more than 24 hours after the incident. G. Staff Training ... C. Such training shall take place during orientation to the hospital and shall be repeated periodically as indicated based on results of performance monitoring/department competency determination. ... iv. Staff in Behavioral Health Care unit shall, in addition, receive training in the following: Response to an agitated or disruptive patient Alternatives when a patient becomes violent Control of own anxiety and professional approach during intervention De-escalation, self-protection, and other appropriate crisis intervention techniques. The safe use of restraint, including physical holding techniques ... ".

Review on March 22, 2017 of MR8 revealed the patient was admitted to the hospital on December 30, 2016, and admitted to the behavioral health unit. Documentation dated February 2, 2017, revealed that on January 30, 2017, MR8 began to pace back and forth in the lounge attempting to grab at items after the patient was not permitted to watch a violent horror movie. The patient was informed of the facility's non-violence policy with no response. The patient continued to grab at items, grabbing a unit art board and attempting to throw it. The patient was stopped from throwing the art board and physically restrained for approximately one and a half minutes. Security arrived at that time. The patient was released from the hold, on the floor, and allowed to sit in a chair.

Review on March 22, 2017 of MR8 revealed the documentation of the physical hold for approximately one and one-half minutes on January 30, 2017, was entered in the medical record on February 2, 2017.

Interview with EMP3 and EMP5 on March 22, 2017, at approximately 3:00 PM, confirmed the documentation of the physical hold for approximately one and one-half minutes on January 30, 2017, was entered in the medical record on February 2, 2017.

There was no documentation in MR8 of the required Leadership Notification or the required debriefing with the patient and/or patient's family within 24 hours after the physical hold. There was no documentation of a staff debriefing within 24 hours after the incident.

Cross reference:
482.13(e)(5) Patient Rights: Restraint or Seclusion
482.13(e)(7) Patient Rights: Restraint or Seclusion
482.13(e)(12) Patient Rights: Restraint or Seclusion
482.13(f)(1) Patient Rights: Restraint or Seclusion

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure a physician's order was obtained for a physical hold for one of four restraint medical records reviewed (MR8).

Findings include:

Review on March 23, 2017, of the facility policy "Restraints," last reviewed July 25, 2016, revealed "Policy: The medical and hospital staff of Robert Packer Hospital (RPH) is committed to preventing and reducing, the use of restraints while maintaining the patient's safety and dignity. A. Definition A. Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely ... A. Requirement for All Setting i. Restraint Order A provider's order is required. If the provider is not available, and in an emergency, a registered nurse, mental health therapist or security guard may initiate restraint in advance of a provider's order and the RN will contact the provider immediately (within a few minutes) for an order and document it within one hour. ... "

Review of MR8 on March 22, 2017 revealed no documentation a physician's order for a physical hold that was implemented on January 30, 2017.

Interview with EMP3 and EMP5 on March 22, 2017, at approximately 3:00 PM, confirmed there was no physician's order in MR8 for a physical hold that was implemented for one and one half minutes on January 30, 2017.

Cross reference:
482.13(e)(4)(ii) Patient Rights: Restraint or Seclusion
482.13(e)(7) Patient Rights: Restraint or Seclusion
482.13(e)(12) Patient Rights: Restraint or Seclusion
482.13(f)(1) Patient Rights: Restraint or Seclusion

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the attending physician was consulted regarding a physical hold for one of four restraint medical records reviewed (MR8).

Findings include:

Review on March 23, 2017, of the facility policy "Restraints," last reviewed July 25, 2016, revealed "Policy: The medical and hospital staff of Robert Packer Hospital (RPH) is committed to preventing and reducing, the use of restraints while maintaining the patient's safety and dignity. A. Definition A. Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely ... The provider shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of the restraint to evaluate the patient's medical and behavioral condition and need for restraint. ..."

Review of MR8 on March 22, 2017, revealed no documentation the attending physician was consulted for a physical hold that was implemented for one and one-half minutes on January 30, 2017.

Interview with EMP3 and EMP5 on March 22, 2017, at approximately 3:00 PM, confirmed there was no documentation the attending physician was consulted for a physical hold that was implemented for one and one-half minutes on January 30, 2017.

Cross reference:
482.13(e)(4)(ii) Patient Rights: Restraint or Seclusion
482.13(e)(5) Patient Rights: Restraint or Seclusion
482.13(e)(12) Patient Rights: Restraint or Seclusion
482.13(f)(1) Patient Rights: Restraint or Seclusion

Based on review of facility documents, medical records (MR), and staff interview (EMP), it was determined the facility failed to ensure the patient was seen face-to-face within one hour of a physical hold for one of four restraint medical records reviewed (MR8).

Findings include:

Review on March 23, 2017, of the facility policy "Restraints," last reviewed July 25, 2016, revealed "Policy: The medical and hospital staff of Robert Packer Hospital (RPH) is committed to preventing and reducing, the use of restraints while maintaining the patient's safety and dignity. A. Definition A. Restraint is any manual method, physical or mechanical device, material, or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely ... The provider shall perform a face-to-face assessment of the patient's physical and psychological status within 1 hour of the initiation of the restraint to evaluate the patient's medical and behavioral condition and need for restraint. ... "

Review of MR8 on March 22, 2017 revealed no documentation the provider performed a face-to-face assessment of the patient within one hour after a physical hold was implemented on January 30, 2017.

Interview with EMP3 and EMP5 on March 22, 2017, at approximately 3:00 PM, confirmed there was no documentation in MR8 the provider performed a face-to-face assessment of the patient within one hour after a physical hold was implemented on January 30, 2017.

Cross reference:
482.13(e)(4)(ii) Patient Rights: Restraint or Seclusion
482.13(e)(5) Patient Rights: Restraint or Seclusion
482.13(e)(7) Patient Rights: Restraint or Seclusion
482.13(f)(1) Patient Rights: Restraint or Seclusion

Based on review of facility documents, personnel files (PF), and staff interview (EMP), it was determined the facility failed to ensure staff restraint training education was completed before staff applied restraints for one of 14 personnel files reviewed (PF9).

Findings include:

Review on March 23, 2017, of the facility policy "Restraints," last reviewed July 25, 2016, revealed "Policy: The medical and hospital staff of Robert Packer Hospital (RPH) is committed to preventing and reducing, the use of restraints while maintaining the patient's safety and dignity. ... G. Staff Training ... C. Such training shall take place during orientation to the hospital and shall be repeated periodically as indicated based on results of performance monitoring/department competency determination. ... iv. Staff in Behavioral Health Care unit shall, in addition, receive training in the following: Response to an agitated or disruptive patient Alternatives when a patient becomes violent Control of own anxiety and professional approach during intervention De-escalation, self-protection, and other appropriate crisis intervention techniques. The safe use of restraint, including physical holding techniques ... "

Review of PF9 on March 23, 2017 revealed the employee was hired September 19, 2016. There was no documentation the facility's required Crisis Prevention Initiate (CPI) training was completed.

Interview with EMP5 on March 23, 2017, at approximately 11:45 AM, confirmed PF9 had not completed the CPI training. As of March 22, 2017, a CPI class was not scheduled. EMP5 revealed the CPI class was to be completed on orientation and every two years; the CPI class was taught by security, when they had time; and the CPI class was an eight-hour class.

Cross reference:
482.13(e)(4)(ii) Patient Rights: Restraint or Seclusion
482.13(e)(5) Patient Rights: Restraint or Seclusion
482.13(e)(7) Patient Rights: Restraint or Seclusion
482.13(e)(12) Patient Rights: Restraint or Seclusion