HospitalInspections.org

Based on interview and document review, the facility failed to obtain a licensed provider restraint order for 1 of 5 patients (P1) prior to, or after, the initiation of a physical/manual hold (violent) restraint.

Findings include:

P1's medical record identified the following emergency department (ED) nurses note, dated 11/9/24 2:45 p.m.: P1 was "very disruptive" and "frightening to the hallway patients," as P1 paced and yelled out. Despite many attempts, P1 was not able to be directed back to her room and the yelling increased. A behavioral emergency response team and "code green" were called and continued attempts to redirect P1's behaviors were attempted; however, response techniques were unsuccessful and P1 continued to be disruptive in the hallway. In response, staff went "hands on" and physically guided her to her room and administered intramuscular (IM) medication injections to P1. Immediately after these administrations, the manual hold on P1 was released. P1 was then directed to sit in a wheelchair, and she was transported by the code team and security to the mental health unit.

P1's ED Care Timeline identified the following:
-11/9/24 at 2:20 p.m. a Violent or Self-Destructive Seclusion Restraints nurse entry indicated an order was obtained by medical doctor (MD)-A for a physical hold as P1 was "manic" and an imminent risk of harm to others.
-11/9/24 at 2:23 p.m., a follow up Restraint Summary nurse entry indicated the restraint was discontinued.
-11/9/24 at 2:25, a nurse entry indicated P1 was transferred out of the ED [to a mental health unit].

On 12/31/24 at 1:34 p.m., during the abbreviated medical record review process with professional practice leads (PP)-A and PP-B, P1's restraint documentation was reviewed. P1's medical record, physician order section, lacked evidence a violent/manual hold order was placed by a licensed provider prior to or after P1's 11/9/24 manual hold. PP-A and PP-B acknowledged inability to locate the required order.

An interview with P1 was attempted; however, was unsuccessful.

When interviewed on 1/2/25 at 11:10 a.m., registered nurse (RN)-A identified she was the vice president of ED services. RN-A explained she expected a qualified provider to input a restraint order into the medical record when a patient required a manual hold for medication administration. RN-A identified she reviewed P1's chart and was unable to identify such an order for P1.

During an interview on 1/2/25 at 11:48 a.m., the ED medical director (MD)-A stated he expected all restraints required a processed order. If a manual hold was required for IM medication administration, he stated he expected the provider would evaluate the patient and the need for such treatment, at which time, if the manual hold was identified, the provider would place a restraint order in the medical record order section. At times, depending on the situation details, a verbal restraint order, would be provided. In those situations, the nurse entered the order and then the provider followed up with their attestation of the order. MD-A explained he was made aware of the lacked order concern after the survey started and indicated this was an opportunity for improvement as "one of the people involved should have caught" the lapse in the process.

When interviewed on 1/2/24 at 3:06 p.m., P1's ED provider (MD)-B stated she was required to input a restraint order into the medical record if such an intervention was required. MD-B explained this step was missed by her for P1 when the manual restraint was applied; however, she was unable to remember any specific details related to P1's situation as a possible reason as to why this step in the "closed loop" restraint process was missed, other than this situation was "a perfect storm" for P1 being she transferred almost right away after the restraint to the mental health unit..

A Restraint or Seclusion policy, dated 3/24/24, indicated its purpose was to ensure a safe environment for both patients and staff, while protecting patient rights, dignity, privacy, and well-being. A Procedure section for Restraint for Violent/Self-Destructive Behavior, with an associated Initiation of Restraint section, directed a licensed provider (LP) ordered the restraint use. If the LP was not immediately available, the RN may initiate the restraint; however, was then expected to obtain an order as it was safe to do so, but no longer than one hour after the initiation of the restraint. The order was to contain a description of the patient actions that necessitated the intervention, a statement that the restraint was to be discontinued when criteria met, type(s) of restraint(s), and order duration (hour hours for individuals greater than or equal to 18 years of age.

Based on interview and document review, the facility failed to provide a face-to-face evaluation (a physical and behavioral assessment of the patient by a qualified practitioner), within an hour of a restraint initiation, for 1 of 5 patients (P1) who were physically restrained.

Findings include:

P1's medical record identified the following emergency department (ED) nurses note, dated 11/9/24 2:45 p.m.: P1 was "very disruptive" and "frightening to the hallway patients," as P1 paced and yelled out. Despite many attempts, P1 was not able to be directed back to her room and the yelling increased. A behavioral emergency response team and "code green" were called and continued attempts to redirect P1's behaviors were attempted; however, response techniques were unsuccessful and P1 continued to be disruptive in the hallway. In response, staff went "hands on" and physically guided her to her room and administered intramuscular medication injections to P1. Immediately after these administrations, the manual hold on P1 was released. P1 was then directed to sit in a wheelchair, and she was transported by the code team and security to the mental health unit.

P1's ED Care Timeline identified the following entries:
-11/9/24 at 2:20 p.m. a Violent or Self-Destructive Seclusion Restraints entry identified a physical hold was needed as P1 was "manic" and an imminent risk of harm to others.
-11/9/24 at 2:23 p.m., a follow up Restraint Summary entry identified the restraint was discontinued.
-11/9/24 at 2:25, a patient transferred entry identified P1 was transferred out of the ED [to a mental health unit].

On 12/31/24 at 1:34 p.m., during the abbreviated medical record review process with professional practice leads (PP)-A and PP-B, P1's restraint documentation was reviewed. P1's medical record lacked evidence a one-hour face-to-face evaluation was conducted after P1's 11/9/24 manual hold. PP-A and PP-B acknowledged inability to locate the required evaluation.

An interview with P1 was attempted; however, was unsuccessful.

When interviewed on 1/2/25 at 11:10 a.m., registered nurse (RN)-A identified she was the vice president of ED services. RN-A explained she expected a qualified staff to conduct the face-to-face and document the specifics of the evaluation in the medical record. These staff included the ED licensed providers and the mental health unit RNs. RN-A identified she reviewed P1's chart and was unable to identify P1 was provided a face-to-face evaluation, either in the ED or once she arrived at the mental health unit.

During an interview on 1/2/25 at 11:48 a.m., the ED medical director (MD)-A stated he expected the ED provider conducted the face-to-face evaluation within 60 minutes of the restraint, even if the restraint lasted for 60 seconds. MD-A explained he was made aware of the lacked face-to-face concern after the survey started and indicated this was an opportunity for improvement as "one of the people involved should have caught" the lapse in the process.

When interviewed on 1/2/24 at 3:06 p.m., P1's ED provider (MD)-B stated she was required to perform a one-hour face-to-face evaluation and document this process into the medical record if a restraint was utilized. MD-B explained this step was missed by her for P1 after the manual restraint was applied; however, she was unable to remember any specific details related to P1's situation as a possible reason as to why this step in the "closed loop" restraint process was missed, other than this situation was "a perfect storm" for P1 being she transferred almost right away after the restraint to the mental health unit.

A Restraint or Seclusion policy, dated 3/24/24, indicated its purpose was to ensure a safe environment for both patients and staff, while protecting patient rights, dignity, privacy, and well-being. A Procedure section for Restraint for Violent/Self-Destructive Behavior, with an associated Face to Face Assessment section, directed within one hour of the initiation of the restraint, the licensed provider (LP) or specifically trained RN, was to conduct an in-person, face-to-face assessment to assess the patient's immediate situation, reaction to the intervention, behavioral condition, need to continue or terminate the restraint, and to perform a complete review of systems with a medical and behavioral status review.