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Based on observation, interview and document review, the facility failed to complete restraint documentation every 15 minutes for the use of physical restraints to manage behavior for 3 of 5 patients (P5, P2, P1) whose records were reviewed for physical restraint use.

Findings include:

P5 was sent to the emergency department (ED) from a group home for accelerating behaviors and out of control which had been progressive over a two week period on according to the hospital report dated 5/15/15. P5 was restrained in the emergency room with appropriate documentation, was admitted to the hospital because a bed was not available for an adolescent psych patient.

The Physician Assessment and Order for Physical/Chemical Restraint indicated: "For violent and self-destructive behavior age 9-17, initial order prior to or immediately after application, renewal every 2 hours, physician assessment every 24 hours. The orders were written on 5/15/15, at 5:30 a.m. initiate chemical and limb. For violent or self-destructive behavior. Additional risk assessment [selected] History of physical or sexual abuse. Start time 5:30 a.m. For violent or self-destructive behavior, age 9-17 :2 hours." The physician renewal was left blank. The criteria for discontinuing restraints was when patient no longer posed a risk of harm to self or others.

The Assessment and Care of the Patient Restraint Daily Flow Sheet dated 5/15/15, at 5:30 a.m. indicated: "Reason for Restraint (selected) was violent aggressive behavior/danger to self or others/physical aggression/impulsive/confused or disoriented/unable to follow directions/ removing medical device-monitoring/attempting to get up/unsafe ambulation. The Checklist (selected) Patients physician notified was time limited order obtained at 5:30 order renewal due (time) at 7:30 [a.m.]-violent behavior age 9-17: 2 hours. Type of restraint (selected) was soft, right wrist, right ankle, left wrist, and left ankle. Restraint applied 5/15/15 at 5:30." [Directions] A check in a box indicated care was provided according to the policy.
-Shift 5:30-7:30 [a.m.] Assessment of: Behavior/response to restraint every 15 minutes. Skin, circulation, and warmth every 15 minutes. Privacy/modesty issues every 15 minutes. Comfort: physical and psychological every 15 minutes. Food and fluid offered every two hours, toileting offered every two hours. Position change and range of motion every two hours self. Restraints released/rotated every two hours. Assessed need for continuation of restraints every two hours (obtain renewal order per policy) was blank.
-Shift 7:00-16:00 [7:00 a.m.- 4:00 p.m.] Assessment of: Behavior/response to restraint every 15 minutes. Skin, circulation, and warmth every 15 minutes. Privacy/modesty issues every 15 minutes. Comfort: physical and psychological every 15 minutes. Food and fluid offered every two hours, toileting offered every two hours. Position change and range of motion every two hours self. Restraints released/rotated every two hours. Assessed need for continuation of restraints every two hours, continued at 9:00, 11:00, 13:00, 15:00.

A nursing shift note at 9:53 p.m. indicated: patient received from ED approximately 5:45 p.m. on stretcher, accompanied by registered nurse (RN) and two emergency medical technician (EMTs) in four point restraints. "Uncooperative while awake, physically aggressive towards staff and known care giver. Non-verbal however he thrashes his extremities, kicks, bites, digs his nails in caregiver's skin, throws his head back repeatedly against the pillow, takes off his diapers and had a bowel movement in the bed. Calmed down to eat, but then starting spitting food on staff." P5's response to the restraint lacked documentation on 5/15/15:
- Between 6:02 a.m. and 6:26 a.m. (24 minutes)
- Between 6:44 a.m. and 7:28 a.m. (42 minutes)
- Between 7:28 a.m. and 7:45 a.m. (17 minutes)
- Between 7:50 a.m. and 8:14 a.m. (24 minutes)
- Between 8:58 a.m. and 9:18 a.m. (20 minutes)
- Between 9:27 a.m. and 9:55 a.m. (28 minutes)
- Between 9:55 a.m. and 10:30 a.m. (35 minutes)
- Between 10:30 a.m. and 11:00 a.m. (30 minutes)
- Between 11:00 a.m. and 11:25 a.m. (25 minutes)
- Between 11:25 a.m. and 11:48 a.m. (23 minutes)
- Between 11:50 a.m. and 12:38 p.m. (48 minutes)
- Between 12:38 p.m. and 12:38 p.m. (17 minutes)
- Between 12:38 p.m. and 1:30 p.m. (35 minutes)
P5's medical lacked the every 15 minute (facility assessed) response to the physical restraint intervention used which included the rationale for continued use of the intervention.

P2 arrived at the emergency department on 3/19/16, at 1:45 a.m. by ambulance with alcohol related problems, belligerence, and combative, in restraints accompanied by police. The patient received Ativan (anti-anxiety) 2 millilgram (mg) intravenously (IV) and remained in physical restraints.

The Physician Assessment and Order for Physical/Chemical Restraint indicated: "For violent and self-destructive behavior age greater than 17, initial order prior to or immediately after application, renewal every 4 hours, physician assessment every 24 hours. The orders were written: On 3/19/16, at 2:00 a.m. end 6:00 a.m. For violent or self-destructive behavior, age greater than 17:4 hours. Physician renewal every 24 hours. Criteria for discontinuing restraints when Patient mentally clear. Poses no threat to self or others."

The Assessment and Care of the Patient Restraint Daily Flow Sheet dated 3/19/16, at 2:00 a.m. The flow sheet indicated: "Reason for Restraint (selected) was violent aggressive behavior/danger to self or others/physical aggression/confused or disoriented/unable to follow directions/ removing medical device IV/attempting to get up/unsafe ambulation. The Checklist (selected) was time limited order obtained at 2:00 [a.m.] order renewal due (time) at 6:00 [a.m.]-violent behavior age greater than 17: 4 hours. Type of restraint (selected) was soft, right wrist, right ankle, left wrist, and left ankle. Restraint applied 3/19/16 at 2:00 [a.m.]. [Directions] A check in a box indicates care was provided according to policy."
-Shift 2:00 Assessment of: Behavior/response to restraint every 15 minutes. Skin, circulation, and warmth every 15 minutes. Privacy/modesty issues every 15 minutes. Comfort: physical and psychological every 15 minutes.

According the emergency room documentation on 3/19/16, at 2:00 a.m. noted P2 was intoxicated, trying to get out of bed. P2 was at risk for harm to self, and attempting to pull out the IV. Restraints were applied. At 2:15 a.m. P2 still trying to get out of restraints, and less anxious than before. The circulation was intact. At 2:15 a.m. P2 received 2 mg of IV Ativan. At 2:43 a.m. starting to fall asleep. Less anxious, restraints in place. At 2:51 a.m. starting to fall asleep, less anxious, restraints in place. At 2:56 a.m. starting to fall asleep, P2 stated he wanted to sleep, physician was notified and the restraints were removed. P2's response to the restraint lacked documentation for the time of 2:15 a.m. to 2:43 a.m. (which was 28 minutes). P2's medical lacked the every 15 minute (facility assessed) response to the physical restraint intervention used which included the rationale for continued use of the intervention.

P1 was an intentional overdose patient in the emergency department from 1/26/16, at 3:49 p.m. and transferred to inpatient admission on 1/26/16, at 6:38 p.m. The Nursing Progress Notes on 1/26/16, at 11:20 p.m. indicated P1 received from the emergency department at 5:00 p.m. unable to keep still, poison control recommended Ativan 1 mg IV. On 1/27/16, at 6:17 a.m. P1 wandered hallway, went into an empty room and climbed up on table, and was caught by staff when she jumped down. On 1/27/16, at 7:17 a.m. P1 was wandering the hallway on average three times an hour, P1 climbed up on wheelchairs and was helped down by charge nurse. On 1/27/16, at 3:09 p.m. the end of P1 combative on and off throughout the day; there was a nurse and nursing assistant in room at all times. P1 was hallucinating and not making sense while talking. On 1/27/16, at 7:12 p.m. the end of shift P1 hallucinating-repetitively seeing, speaking and gesturing to snowflakes, people, rosaries, tin cans and wallets. "At approximately 5:00 p.m. patient became increasingly agitated and combative-screaming, crying, thrashing, banging head against the wall and using verbally abusive language." Verbally and physically redirected by staff. Ativan given twice with minimal improvement of behavior and/or mood. Physician and poison control updated. On 1/27/16, at 8:00 p.m. restless and pacing in room, had made multiple attempts to leave room. P1 was throwing blankets and water pitchers on floor. She was swearing and aggressive towards two staff members in room. "Continues to hallucinate talking about the king and being a snow queen, picking objects out of the air." Became physically and verbally abusive to staff, assistance called to restrain patient.

The Physician Assessment and Order for Physical/Chemical Restraint indicated: For violent and self-destructive behavior age 9-17, initial order prior to or immediately after application, renewal every two hours, physician assessment every 24 hours. The orders were written on 1/27/16 (the 7 was written over) at 8:00 (the first 0 was written over). Initiate-limb restraint-violent or self-destructive behavior-(start and stop times were blank)-age 9-17: two hours-next face to face physician evaluation required 24 hours-discontinue when no longer risk of harm to self/others.

The Assessment and Care of the Patient Restraint Daily Flow Sheet dated 1/27/16, indicated the "Reason for Restraint (selected) was violent aggressive behavior/danger to self or others/physical aggression/impulsive/confused or disoriented/unable to follow directions/attempting to get up/unsafe ambulation. The checklist (selected) was patient's physician notified, time limited order obtained at 8:00 p.m. order renewal due (time) at 10:00 p.m.-violent behavior age 9-17: 2 hours. Type of restraint (selected) was soft, right wrist, right ankle, left wrist, and left ankle.
-Restraint applied 1/27/16, at 8:00 p.m." The hospital assessed that P1 was to be checked every 15 minutes for behavior/responses to the restraint, skin, circulation and warmth, and for physical and psychosocial comfort.

The Nursing Progress Notes written on 1/28/16, at 1:00 a.m. noted the charge nurse was called to P1's room at 7:45 p.m. patient had struck RN watching her and was physically and verbally assaultive. P1 was agitated and incoherent. P1 was placed in restraints with assistance of multiple staff members and house supervisor. "Ativan given IV to effect. Resting comfortably at that time. Restraints removed at 1:00 a.m." P1's response to the restraint lacked documentation 7:45 p.m. to 1:00 a.m. which was five hours and 15 minutes. P1's medical lacked the every 15 minute (facility assessed) response to the physical restraint intervention used which included the rationale for continued use of the intervention.

On 5/5/16, at 1:30 p.m. the chief nursing officer (CNO) stated the form they used to document restraints had the check box of every 15 minutes, which was used to document that you were with the patient as a 1:1 and so had observations of them every 15 minutes. The CNO did verify that the hourly rounding sheet which was sometimes used, did not include every 15 minute documentation of what the resident was doing [to justify continuation of the restraint].

On 5/5/16, at 2:00 p.m. the director of quality assurance (QA) reviewed the documentation and verified that the restraint documentation form lacked every 15 minute documentation of patient behavior to determine if continuation of restraints was justified (i.e. pacing, or cooperative).

The Care of Behavioral Health Patients policy dated 7/2011, indicated:
" 10. Staff members observe the patient at all times within the ED [Emergency Department], and when 1:1 observation is required on the Medsurg unit [Medical/Surgical], including bathroom or shower use.
12. The nurse documents assessments during the patients stay at a frequency determined by the patient's need (e.g., every 15 minutes if the patient is restrained for violet behavior).
On the Meditech 'Behavioral Health Assessment' screen in the ED.
On the Meditech 'Behavioral and Mood Assessment' screen in the Medsurg unit."

Based on observation, interview, and record review, the hospital was found to be out of compliance with Life Safety Code requirements. These findings have the potential to affect all patients in the hospital.

Findings include:

Please refer to Life Safety Code inspection tag: K-0062.