HospitalInspections.org

Based on medical record and policy review it was determined that the nursing staff failed to obtain physician orders to continue the use of restraints for Patient #1.

The findings include:

Policy Number NUR-008-10 entitled Restraint and Seclusion, last revised April, 2010 within the Procedure section, Initiation of restraints stipulates " 1. In an emergency, HUH authorizes Registered Nurses, qualified through training and competency assessments, to initiate the use of restraints prior to obtaining an order from the patients treating physician/resident. Continued use occurs pursuant only to an order by the physician having primary responsibility for patient ' s ongoing care, that is the attending or treating physician ... "

Policy Number NUR-008-10 entitled Restraint and Seclusion, last revised April, 2010 within the Procedure section, Restraint or Seclusion Orders stipulates " ... 4. Orders for restraint or seclusion are limited to the following: 4 hours for adults ... "


Patient #1 was admitted August 29, 2012 with diagnoses to include Rhabdomyolysis and Altered Mental Status. Review of the medical record revealed at 11:45 AM on August 29, 2012, the patient was placed in four (4) point restraints for safety reasons after an attempt to elope from the Emergency Department (ED).

The ED physician wrote an order for restraint duration of four (4) hours. Review of the One to One Observation Restraint Record revealed the patient was initially aggressive, combative, experiencing auditory hallucinations, and inappropriate. The Restraint record reflects the patient was restrained from 11:45 AM until 23:00 (11:00 PM). The medical record lacked documented evidence that the nursing staff obtained an order to continue the restraints beyond the four (4) hour limit as ordered by the ED physician.

The nursing staff failed to obtain an order to continue the use of restraints.

Based on medical record and policy review it was determined that the clinical staff failed to discontinue restraints at the earliest possible time, assuring the patient ' s right to be free from restraint (Patient #1).

The findings include:

Policy Number CMR-26-ASP entitled Patient Rights and Responsibilities, last reviewed May, 2010 stipulates within the Policy section, Item A.1 " ...k. to ensure that restraint or seclusion, of any form, is imposed safely by trained staff only to ensure the immediate physical safety of patients, our staff, or others, and to discontinue the restraint or seclusion at the earliest possible time ... "

Policy Number NUR-008-10 entitled Restraint and Seclusion, last revised April, 2010 within the Procedure section, Restraint Use for the Non-violent or Non-Self Destructive Patient stipulates " 1. Clinical Justification: ... Confused and/or disoriented to the degree that the patient is not responsible for safe decision making and may accidentally or purposefully harm him/herself ... The use of restraint must be documented in the patient ' s plan of care. "

Policy Number NUR-008-10 entitled Restraint and Seclusion, last revised April, 2010 within the Procedure section, Initiation of restraints stipulates " 1. In an emergency, HUH authorizes Registered Nurses, qualified through training and competency assessments, to initiate the use of restraints prior to obtaining an order from the patients treating physician/resident. Continued use occurs pursuant only to an order by the physician having primary responsibility for patient ' s ongoing care, that is the attending or treating physician ... "


Patient #1 was admitted August 29, 2012 with diagnoses to include Rhabdomyolysis and Altered Mental Status. Review of the medical record revealed the physician ordered the patient placed in four (4) points restraints at 11:45 AM on August 29, 2012 for aggressive behavior and attempting to flee.

Review of the One to One Observation Restraint Record revealed the patient was initially aggressive, combative, experiencing auditory hallucinations, and inappropriate. At 12:20 PM the patient was noted to be inappropriate, aggressive and experiencing auditory hallucinations, and was subsequently administered anti-anxiolytic and anti-psychotic medications which were successful in symptom control as supported by the nurses ' documentation of the patient ' s behavior.

The Restraint Record reflects the patient was monitored every half-hour from 12:30 PM through 8:00 PM. The patient ' s behavior was noted as " sleeping " from 1:30 PM through 7:00 PM; at 8:00 PM and 11:00 PM noted as " calm and cooperative " ; and 9:00 PM and 10:00 PM noted as " sleeping " . The behaviors no longer justified the use of restraints.

The Restraint Record further reflects that the patient ' s restraints were not released or rotated from 11:45 AM until 11:00 pm on August 29, 2012.

The clinical staff failed to assure the patient was released from restraints at the earliest possible time in accordance with behaviors.

1. Based on medical record and policy review and staff interview it was determined that the clinical staff failed to document all information necessary to monitor the patient ' s condition as evidenced by the lack of a completed Assault/Violence Assessment Tool per hospital policy for Patient #1.

The findings include:

Policy Number NUR-037-10 entitled Management of Patients at Risk of Harming Self or Others, last reviewed March 2008 stipulates " Purpose: To provide guidelines for the safety of patients with self-destructive/violent thoughts and actions. Scope: All staff are responsible for acting within the scope of their practice to protect patients who are determined to be at risk to themselves and/or other. Policy: ...The level of precaution is determined by the risk assessment (See Suicide Risk Protocol and Violence Risk Protocol). Suicide/Violence Precautions may be ordered by physician or initiated by the registered nurse. I. Responsibilities: A. Physician/Resident - Upon completion of initial evaluation will assign a risk level for the patient based on the total risk score; will write an order that will reflect the care associated with the assigned risk level ... B. Nurse - Initial assessment: The patient ' s risk for suicide /violence is assessed by completing the " Suicide Risk Assessment Tool " HUH3300 and/or " Assault/Violence Assessment Tool; match behavior pattern with risk score and provide the appropriate intervention ... "

Patient #1 was admitted August 29, 2012 with diagnoses to include Rhabdomyolysis and Altered Mental Status. Review of the medical record revealed the lack of determination of the level of precaution regarding the patient ' s risk for harm to self and/or others. The medical record lacked documented evidence of the " Assault/Violence Assessment Tool " .

Further, the admitting History and Physical Examination lacked documented evidence that the patient ' s judgment, insight, and affect were assessed in order to determine the need for continued one to one observation.

The clinical staff failed to document all information necessary to monitor the patient ' s condition and comply with hospital policy regarding assessment of patients at risk for harm