HospitalInspections.org

The facility failed to protect and promote each patient's rights as evidence by:

1. Based on review of documentation and interview, the facility failed to ensure the right of patients to be free from corporal punishment, as evidence by hospital employed security staff applying handcuffs as restraint that did not result in law enforcement action. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. Please cross refer to A0154.

2 The facility failed to ensure that the condition of the patient who is restrained must be monitored by a physician, other licensed practitioner or trained staff at an interval determined by hospital policy. Please cross refer to A0175

Based on review of documentation and interview, the facility failed to ensure the right of patients to be free from corporal punishment, as evidence by hospital employed security staff applying handcuffs as restraint that did not result in law enforcement action. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.

CMS policy regarding the use of restraint stated, "CMS does not consider the use of weapons in the application of restraint or seclusion as a safe, appropriate health care intervention. For the purposes of this regulation, the term "weapon" includes, but is not limited to, pepper spray, mace, nightsticks, tasers, cattle prods, stun guns, and pistols ...If a weapon is used by security or law enforcement personnel on a person in a hospital (patient, staff, or visitor) to protect people or hospital property from harm, we would expect the situation to be handled as a criminal activity and the perpetrator be placed in the custody of local law enforcement.

The use of handcuffs, manacles, shackles, other chain-type restraint devices, or other restrictive devices applied by non-hospital employed or contracted law enforcement officials for custody, detention, and public safety reasons are not governed by this rule. The use of such devices are considered law enforcement restraint devices and would not be considered safe, appropriate health care restraint interventions for use by hospital staff to restrain patients. The law enforcement officers who maintain custody and direct supervision of their prisoner (the hospital's patient) are responsible for the use, application, and monitoring of these restrictive devices in accordance with Federal and State law. However, the hospital is still responsible for an appropriate patient assessment and the provision of safe, appropriate care to its patient (the law enforcement officer's prisoner)."


Findings included:

On 08/03/21, staff member #2 verified that security guards working at the facility are employed by the hospital, there are not contracted law enforcement officials. The security guards are employed by the facility. Often Austin Police Department Officers (APD) are on-site for other duties, but APD is not contracted to provide security at the facility.

The facility had 6 occurrence of hospital employed security officers applying handcuffs to patients at the facility. Record review revealed that in 3 out of 6 applications of handcuffs as restraints on patients (#10, 11, and 12) at the facility did not result in criminal charges or arrest of the patients. 3 of the 6 patients (#13-15) arrested and placed in APD (Austin Police Department) custody.

Patient #10

* Nursing note entered on 04/26/21 stated in part, "Pt followed MD Duncan out of the room, yelling. security followed several feet behind the pt. pt then turned around and lunged at security ... pt fell to the ground, hitting his head on a mobile work computer. pt's head laceration was immediately wrapped. pt was in cuffs."

* Physician note on 04/25/321 stated in part, "However when APD came to assess the patient after his altercation with security staff, APD opted to place the patient on POED rather than under arrest due to no substantial injury being reported by those struck by the patient."

* Review of Emergency Department video surveillance on the evening of 04/25/21 viewed on 08/03/21 by surveyors revealed that hospital employed security officers did apply handcuffs to this patient.

* In interview on 08/02/21, the hospital employed security guard verified the patient was in handcuffs in the ED and released to have a computerized tomography (CT) performed.

* The patient was not placed into police custody and eloped from the facility later that evening.

* There was no order for this use of handcuffs as restraints. No less restrictive methods of de-escalating the patient's aggressive behavior was documented in the medical record. It is unknown how long the patient was in handcuffs prior to release to have a medical test (CT performed). No monitoring of the patient while in handcuffs was documented


Patient #11

* According to the Security Incident Report: A code gray was called at 1406. The patient said they were going home and came out of the room in a aggressive manner, pushing in staff. He was re-directed to the ground with 2 other security officers assisting. Handcuffs were applied while waiting for staff to administer medication. He was given 2 shots and assisted to his feet, put back in his room where he was uncuffed and placed in 4 point restraints.

* A case management note on 03/11/21 at 1448 stated in part, "Pt came out of his pt room and attempted to assault Colton with Security. Pt was taken to the ground be [sic] Security, handcuffed and placed back in bed with 4 pt restraints."

* There was no order for this use of handcuffs as restraints. No less restrictive methods of de-escalating the patient's aggressive behavior was documented. It is unknown how long the patient was in handcuffs prior to transitioning to the 4 point medically approved device. No monitoring of the patient while in handcuffs was documented


Patient #12

* Nursing note on 03/29/21 at 10:28 PM stated in part, "Two other staff members went into room to assist, pt became aggressive and combative, and refused to sit back down in bed. Patient then punched a staff nurse in the head. Code gray was called, ....pt placed in 4 point soft restraints."

Nursing note on 04/01/21 at 0129 stated in part, "pt was threatening staff w/ violence; called security when they got here he pt swung and hit guard, security then restrained pt; APD was called and arrested pt and took him to jail."

* There was no order for this use of handcuffs as restraints. No less restrictive methods of de-escalating the patient's aggressive behavior were documented. It is unknown how long the patient was in handcuffs prior to transitioning to the 4 point medically approved device. No monitoring of the patient while in handcuffs was documented.

The above findings were verified on 08/03/21 with staff members #1 and 2.


In 3 of 6 occurrences local law enforcement was contact and decided not to press charges or place patients into police custody. The facility employed security personnel kept the patient in handcuffs after the local law enforcement left the facility. The use of such devices such as handcuffs are considered law enforcement restraint devices and are not considered safe, appropriate health care restraint interventions for use by hospital staff (such as hospital employed security) to restrain patients.

The facility also failed to document appropriate patient assessment and the provision of safe, appropriate care, including monitoring of patients in handcuffs at the facility. The use of handcuffs could lead to possible injury to patients, monitoring of the patient in handcuffs would minimize the potential for harm.

Based on review of documentation and interview, the facility failed to ensure that the condition of the patient who is restrained must be monitored by a physician, other licensed practitioner or trained staff at an interval determined by hospital policy.

Findings included:

Facility based policy entitled, "· Restraints ·and Safety-Alternatives - Use of -Medical/Surgical Acute Care Facilities" stated in part, "This policy applies to:

Physical devices or medications used as a restraint are:

o Used only to protect the immediate physical safety of the patient, staff, or others.

o Used only when alternative interventions are ineffective

o Not used as a means of coercion, discipline, convenience, or staff retaliation

o Discontinued at the earliest possible time, regardless of the scheduled expiration of the order ...

o Forensic and correction restrictions used for security purposes. The law enforcement officer assigned to the patient is responsible for monitoring the security of the patient while shackled for~ forensic or law enforcement purposes. However, restraint use related to the clinical care of these patients requires compliance with this policy ...

Definitions ...

Restraint: any manual method, physical or mechanical device or equipment that immobilizes or reduces the ability of a patient to move his or her arms, legs, body, or head freely or drug used as a restraint. This includes a physical hold. (See Restraint and Safety Alternatives/Attachment-Restraint Devices ...

Least Restrictive Restraint Device: The restraint device that only limits the patient's mobility to the point necessary to protect the physical safety of the patient, staff, or others. Always ensure you use the most appropriate device for the situation that is the least limiting for the patient.

Non-Violent Restraint is used when:

o Patient interference with medical treatment or devices which threatens the patient's plan of care, and the use directly supports the medical healing of the patient. This includes agitation/excessive movement that could result in negative clinical outcomes such as device dislodgement. (Example: The patient whose confusion is due to a medical condition; this patient is not in full control over this behavior).

o Alternatives to restraint have proven ineffective or not viable ....

Restraint Monitoring: includes visual check, assisting with range of motion, elimination; nutrition and hydration, and hygiene needs along with physical and mental comfort status. ·

o For non-violent restraint, monitoring occurs at a minimum every 2 hours or more frequently as determined by the patient's condition.

o For violent restraint, monitoring occurs through direct visual contact at a minimum of every 30 minutes or more frequently as determined by the patient's condition ...

Key Points

A. The initiation of the restraint process is not driven solely by a patient's diagnosis, previous restraint history, or a patient's history of violent or dangerous behavior.

B. Restraints may only be used in accordance with written modifications to the patient's plan of care.

C. The least restrictive form of restraint that protects the physical safety of the patient, staff, or others should always be used ....

H. If a patient becomes danger to self or others (unrelated to, or a symptom of a medical diagnosis) and his or her behavior necessitates a restraint then initiation of a violent restraint order is required. See Restraints and Safety Alternatives

ATTACHMENT - Emergency Restraint Management Guideline.

J. Restraints may be applied when ordered by, a licensed physician or other advanced practice provider (PA or APRN) who is responsible for the care of the patient, except in situations where the Emergency Management Guideline is utilized.

* Usage of restraints, non-violent or violent requires a written order ....

Procedures

See Restraints and Safety Alternatives ATTACHMENT~ Ascension Texas Summary of Restraint Required Elements.docx

RESPONSIBILITIES:

Physicians (including residents) and other licensed independent practitioners

1. Responsible to have a working knowledge of and comply with restraint policy and procedure:

2. Provide verbal and written orders for the appropriate use of restraints.

3. (Violent restraints only) Provide face-to-face patient evaluations/re-evaluations to determine the need for continued restraint and the need to revise the care plan, treatment and services. Evidence of the medical evaluation and the findings must be documented in the medical record, including:

a. An evaluation of the patient's immediate situation

b. The patient's reaction to the intervention

c. The patient's medical and behavioral condition

d. The need to continue or terminate the restraint.

4. The Physician may delegate the face-to-face assessment to a Physician Assistant or Advanced Practice

Registered Nurse.

Registered Nurses:

1. Responsible for all aspects of care of the patient in restraints, to include:

* Perform the initial assessment for the need for restraint

* Receive orders from the attending physician or other licensed independent practitioner

* Perform re-assessments for restraint order renewal within required time frames and to assure restraint is discontinued as soon as possible

* Apply, monitor, discontinue and/or remove restraints

* Document according to Procedure C ...

PROCEDURES:

C. Documentation in the medical records includes at a minimum:

* The consideration and/or use of alternatives to restraint

* Patient's response to alternatives

* The physician restraint orders

* The physician evaluations and any consultations

* The nursing assessments and reassessment

* The patient's condition or symptom(s) that warranted the use of the restraint and the intervention used

* The intervals and results of monitoring the patient ...

* The patient's response to the restraint(s) used including the rationale for the continued use of the intervention"


Facility Policy entitled, "Ascension Texas Security Policy Security Handcuffs 1004.09" stated in part,

"I. . Handcuffs may only be used by an Ascension Security Officer if the officer is trained and authorized by the Director of Security.

A. Any use of handcuffs will be documented in accordance with Ascension Security's Use of Force policy.

B. Handcuffs are to be used for three types of situations:

1. To protect another individual who is being assaulted or to prevent an. assault.

2. To temporarily restrain an actively aggressive/physically combative person in order to protect themselves or others from harm until medical restraints can be applied.

3. To arrest an individual who has violated a State Law that a Ascension Security Officer has personally observed, provided the officer has the authority to affect an arrest and will only detain that individual until released to Law Enforcement, unless approved by a Site Lead or Security Manager.

C. Once handcuffs are applied, the individual must be transitioned into medical restraints in the shortest amount of time possible, if applicable. An individual should not be restrained to an object with handcuffs."


The facility had 6 occurrence of hospital employed security officers applying handcuffs to patients at the facility. Record review revealed that in 3 out of 6 applications of handcuffs as restraints on patients (#10, 11, and 12) at the facility did not result in criminal charges or arrest of the patients. There was no documented monitoring of these patients while in handcuffs. 2 of the 3 patients were transitioned from handcuffs to medically approved 4 point restraints, however these patients were not monitored appropriately per policy.


Patient #10

* Nursing note entered on 04/26/21 stated in part, "Pt followed MD Duncan out of the room, yelling. security followed several feet behind the pt. pt then turned around and lunged at security ... pt fell to the ground, hitting his head on a mobile work computer. pt's head laceration was immediately wrapped. pt was in cuffs."

* Physician note on 04/25/321 stated in part, "However when APD came to assess the patient after his altercation with security staff, APD opted to place the patient on POED rather than under arrest due to no substantial injury being reported by those struck by the patient."

* Review of Emergency Department video surveillance on the evening of 04/25/21 viewed on 08/03/21 by surveyors revealed that hospital employed security officers did apply handcuffs to this patient.

* In interview on 08/02/21 the hospital employed security guard verified the patient was in handcuffs in the ED and released to have a computerized tomography (CT) performed.

* The patient was not placed into police custody and eloped from the facility later that evening.

* There was no physician order for this use of handcuffs as restraints. No less restrictive methods of de-escalating the patient's aggressive behavior was documented in the medical record. It is unknown how long the patient was in handcuffs prior to release to have a medical test (CT performed). No monitoring of the patient while in handcuffs was documented


Patient #11

* According to the Security Incident Report: A code gray was called at 1406. The patient said they were going home and came out of the room in a aggressive manner, pushing in staff. He was re-directed to the ground with 2 other security officers assisting. Handcuffs were applied while waiting for staff to administer medication. He was given 2 shots and assisted to his feet, put back in his room where he was uncuffed and placed in 4 point restraints

* A case management note on 03/11/21 at 1448 stated in part, "Pt came out of his pt room and attempted to assault Colton with Security. Pt was taken to the ground be [sic] Security, handcuffed and placed back in bed with 4 pt restraints."

* There was no order for this use of handcuffs as restraints. No less restrictive methods of de-escalating the patient's aggressive behavior were documented. It is unknown how long the patient was in handcuffs prior to transitioning to the 4 point medically approved device. No monitoring of the patient while in handcuff was documented

* This patient had violent restraint physician order for 4 point restraints on 03/11/21 at 1457. Restraint documentation reflected the patient was in 4 point restraints from 1400-1500. Checks were only documented on the patient at 1400 and 1500. This does not meet the criteria for monitoring every 30 minutes for violent restraints per policy.

* This patient had another restraint (non-violent interfering with medical devices) episode documented on 03/12 from 0800 to 1030. There was no physician order for this second restraint episode per policy.


Patient #12

* Nursing note on 03/29/21 at 10:28 PM stated in part, "Two other staff members went into room to assist, pt became aggressive and combative, and refused to sit back down in bed. Patient then punched a staff nurse in the head. Code gray was called, ....pt placed in 4 point soft restraints.

Nursing note on 04/01/21 at 0129 stated in part, "pt was threatening staff w/ violence; called security when they got here he pt swung and hit guard, security then restrained pt; APD was called and arrested pt and took him to jail."

* There was no order for this use of handcuffs as restraints. No less restrictive methods of de-escalating the patient's aggressive behavior were documented. It is unknown how long the patient was in handcuffs prior to transitioning to the 4 point medically approved device. No monitoring of the patient while in handcuff was documented.

* This patient had violent restraint physician order for 4 point restraints on 03/29/21 at 1006. Restraint documentation reflected the patient was in 4 point restraints from 03/29/21 0900-1300. Checks were only documented on the patient at 0900, 1130, and 1300. This does not meet the criteria for monitoring every 30 minutes for violent restraints per policy.

* A non-violent restraint physician order was present on 03/29/21 at 1442 for 4 point restraints. Restraint documentation reflected the patient was in 4 point restraints from 03/29/21 1441-0141 on 03/30/21. Checks were only documented on the patient at 1441, 1524, 2000, 2200, 0000, and 0141. This does not meet the criteria for monitoring every 2 hours for non-violent restraints per policy. In fact there was a 4 hour gap in monitoring per documentation.


The above findings were verified on 08/04/21 with staff members #1 and 2. The above three patients were not monitored and/or assessments documented while in handcuffs. 2 of the 3 patients (#11 and 12) were not appropriately monitored per facility policy once transitioned to the medical restraints.