HospitalInspections.org

Based on record review and interview, the facility failed to document restraint/seclusion orders, face-to-face evaluations, and/or monitoring for 3 (#2, 5, 6) of 3 patients reviewed for restraint/seclusion and failed to provide an informed anesthesia consent to 1 (#7) of 3 patients reviewed for anesthesia consents resulting in the potential for loss of patient rights and poor patient outcomes. Findings include:

See Specific Tags:

A-131 Failure to specify type of anesthesia being provided
A-168 Failure to have a physician order/renewal for restraint
A-175 Failure to monitor the patient during restraint
A-178 Failure to conduct a 1-hour face-to-face evaluation

Based on record review and interview, the facility failed to provide an informed consent for anesthesia to 1 (#7) of 3 patients reviewed for anesthesia consents resulting in the loss of patient rights and the potential for unrecognized, unsafe patient outcomes. Findings include:

On 1/11/2024 at 1451, review of the medical record for P-7 revealed an anesthesia consent that was signed by the provider and the patient; however, the type of anesthesia to be given was left blank.

On 1/11/2024 at 1455, Staff G was queried as to if the type of anesthesia was to be indicated on the consent. She stated that was why the boxes on the consent were present.

Facility policy #0203 titled "Standard Practice Patient Rights and Responsibilities" last revised 8/13/2021 states, "A patient is entitled to... Receive, from the appropriate individual within the facility, information about his or her medical condition, proposed course of treatment, informed consent, prospects for recovery, and ability to make decisions relating to end of life care, in terms and in a language that the patient can understand, unless medically contraindicated as documented by the attending physician in the medical record."

Based on record review and interview, the facility failed to have a physician order or renewal order for 2 (#5, 6) of 3 patients reviewed for restraints resulting in the loss of patient rights and the potential for unsafe patient outcomes. Findings include:

On 1/11/2024 at 1359, review of the medical record for P-5 revealed restraints were initiated on 11/19/2023 at 1938. The face-to-face evaluation was done at 1944, and the restraints were discontinued at 2002. The order for the restraint was given at 2030 (52 minutes post initiation, 46 minutes post face-to-face evaluation, and 28 minutes post discontinuation).

On 1/11/2024 at 1415, Staff G was queried as to why the order would have been given so long after the restraint process was complete. She stated it must have been noticed the order was not obtained and was entered late.

On 1/11/2024 at 1427, review of the medical record for P-5 revealed an order was given on 6/29/2023 at 2109 for 4-point locking restraints for a duration of 2 hours. Restraints were initiated at 2100 and were discontinued on 6/30/2023 at 0020 (3 hours, 11 minutes). No renewal order was given for the additional 1 hour and 11 minutes past the original 2 hour order.

On 1/11/2024 at 1435, Staff G stated, "This is not good."

Review of facility policy #0217 titled "Standard Practice Restraint and Seclusion" last revised 11/29/2023 states, "Each order for restraint or seclusion used for the management of violent or self-destructive behavior may only be ordered in accordance with the following limits: 4 hours for adults 18 years of age or older; 2 hours for children and adolescents 9 to 17 years of age; 1 hour for children under 9 years of age The order can be renewed by a physician for a total of 24 hours before a face to face evaluation by a physician must be completed.If the patient needs the restraint or seclusion order renewed, it must be completed prior to the expiration of the current order but no
greater than 30 minutes prior to expiration; otherwise a new order must be obtained."

Based on record review and interview, the facility failed to monitor 1 (#6) of 3 patients reviewed for restraint/seclusion resulting in the potential for unsafe patient outcomes. Findings include:

On 1/11/2024 at 1427, review of P-6's medical record revealed an order for 4-point locking restraints on 6/29/2023 at 2109 for a duration of 2 hours. Review of the restraint flowsheet documentation indicated the restraints were initiated at 2100. No monitoring documentation is present until the restraints were discontinued on 6/30/2023 at 0020.

On 1/11/2024 at 1440, Staff G stated there was no documentation and did not understand why it was not present. She went back and verified the order and the discontinuation of the restraint.

Review of facility policy #0217 titled "Standard Practice Restraint and Seclusion" last revised 11/29/2023 states, "Immediate assessment by a trained RN after restraints are applied to ensure proper and safe application. Documentation of restraint type daily and with change in limbs restrained and type of restraint. Patients in violent or self-destructive behavior restraints must be monitored with direct 1:1 observation Frequency of monitoring may be increased based on patient condition. Every 2 hour monitoring required to be completed by a trained RN includes:
assessment of patient safety; readiness for release from restraints; clinical justification. At least every 4 hours VS(vital signs) monitoring if patient is being medicated (document in VS flowsheet) Every 15 minute monitoring, q2hr
monitoring (as mentioned below) and q4hr VS can be done by a trained patient unit aide, nursing assistant, mental health tech, ED tech or RN Every 15 minute monitoring includes: Visual check, Psychological status, Physical comfort, Circulation Every 2 hour monitoring includes: Fluid/hydration needs, Hygiene/toileting/elimination needs, Range of Motion."

Based on record review and interview, the facility failed to provide a face-to-face evaluation within one hour of restraint or seclusion for 2 (#2, 5) of 3 patients reviewed for restraint/seclusion resulting in the potential for violation of patient rights and poor patient outcomes. Findings include:

On 1/11/2024 at 1313 review of the medical record for P-2 revealed she was placed into seclusion on 10/5/2023 at 1036. Restraint flowsheet documentation stated in the section for face-to-face evaluation "No", indicating the face-to-face evaluation had not been done.

On 1/11/2024 at 1359, review of the medical record for P-5 revealed she had been placed in restraints multiple times. Face-to-face evaluations were not completed for 5 (11/1/2023, 11/17/2023, 11/23/2023, and twice on 11/24/2023) of 11 times she was placed in restraint. The documentation revealed the following:
11/1/2023 Face-to-face evaluation left blank
11/17/2023 Face-to-face evaluation stated, "No"
11/23/2023 Face-to-face evaluation stated, "No."
11/24/2023 at 0030 Face-to-face evaluation left blank.
11/24/2023 at 1148 Face-to-face evaluation left blank.

On 1/11/2024 at 1415, Staff G stated, "It should be documented right here... This makes us look really bad."

Faciliy policy #0217 titled "Standard Practice Restraint and Seclusion" last revised 11/29/2023 states, "The patient must be seen face to face, by a physician, within 1 hour after the initiation of the intervention to evaluate: The patient's immediate situation; The patient's reaction to the intervention; The patient's medical and behavioral condition and
The need to continue or terminate the restraint or seclusion."