HospitalInspections.org

This regulation is not met as evidenced by:

Based on an onsite investigation in which policy and procedure, interviews, and 15 patient records were reviewed, patients #11 and #12 of 15 patient records show no durations for their restraint/seclusion orders.

No restraint/seclusion durations appear on orders written in the emergency department (ED). Interview and demonstration of order entry with the Chief Medical Officer reveals a drop-down box for entering the appropriate time limits for restraint and seclusion.

Patient #11 is a 15-year-old male who presented to the emergency department (ED) on 1/30/2011 at 10:45 pm via police with an emergency petition following his stated intention to kill himself. Patient #1 became combative and was placed in 4-point restraint at 1:30 am. An order titled Behavioral Restraint Initiation on 1/31/2011 at 2:31 am reads, " Protect from accidental injury, leather cuffs." No duration is noted on the order. Patient #11 remained in restraint from 1:30 am until 2:49 am. The documented restraint total time is 1 hour, though patient #11 was actually in restraint for one hour and 19 minutes.

Patient #12 is a 28-year-old mentally retarded female who presented to the ED on 12/27/2010 after becoming agitated in her group home where she began to spit on persons there, and began throwing things. Patient #12 has a history of seizures and developmental disabilities. An initial assessment by the physician revealed pressured speech, and she was not redirectable. Patient #12 began to throw things, and was cursed at staff. An behavioral seclusion order of 12/28 at 9 am states Protect from injury to self and others, Seclusion. No time duration is noted in the order. Patient #12 was secluded from 8:45 am to 10:15 am. The documented total behavioral restraint time was 1 hr, when it had actually been 1.5 hours.

While neither of the surveyed records surpassed regulatory time limitations, the hospital failed to document the time limitations in the actual orders.

Based on an onsite investigation in which policy and procedure, interviews, and 15 patient records were reviewed, patient #14 was not released from restraint/seclusion at the earliest possible time as evidenced by:

Patient #14 is a 50-year-old female admitted on 12/14/2010 to the behavioral health unit from another hospital. Patient #14 had been showing bizarre behaviors in her home where she lives with her mother and daughters. She had not been sleeping or eating well, and was burning pictures and leaving lit papers around the house. She appeared suspicious of others, and unplugged phones and the microwave. At times, she would spit at, or hit family members. Patient #14 was observed to be responding to internal stimuli, and has a history of psychiatric hospitalization in her 20s. She received a diagnosis of Bipolar disorder, manic, severe, with psychotic features.

On 12/15/2010 at 11:45 pm, patient #14 came out of her room with a gait that appeared as though she might fall. Staff assisted her to a chair. Patient #14 expressed to staff that she felt "Afraid" and that "My legs feel heavy." When asked if she wanted to sleep in the quiet room closer to the nursing station, patient #14 instead went back to her room. She came out again at 11:50 pm and reported she had "Bad thoughts." Staff prepared medication for her, but patient #14 abruptly went to the fire alarm, and pulled the alarm.

Patient #14 was asked to go to the Open Door Quiet Room, but refused and began running around the unit. On approach, she became combative. Security arrived on the unit and placed patient #14 in Locked Door Seclusion at 1:10 am. A nursing initiation note of 12/16 at 2:16 am states criteria for restraint/seclusion removal as "Patient will have to be assessed by psychiatrist in am due to unpredictable behaviors she presents a danger to herself and other patients on the unit. The patient's doctor will need to evaluate what criteria pt. needs to exhibit to be released."

A psychiatry note of 2:20 am states "Pt. in locked door seclusion, no evidence of injury or distress." The note addresses the patient's immediate situation and her medical condition, but does not address the patient behavior, immediate reaction or the need to continue the intervention.

A nursing note at 3 am states in part, "When patient was told that she had to go into the QR (quiet room, patient became combative and aggressive. Patient required hands on by the 3 security guards to get patient on the bed. Patient did calm down and was then released when she promised she would not struggle with staff. Patient agreed to received a prn Zyprexa 5 mg IM was administered at 0110. Dr. ___ was called for an order at 0115. Dr. ___saw the patient at 0210. Patient has been given water and has not been a management problem since being in LDS (locked door seclusion). The patient's behavior was unwarranted and unpredictable " ... " The patient will continue in LDS until Dr. ___ sees the patients in the am and evaluates if the patient can be on the unit safely."

Patient #14 is documented on the 15-minute flows as "lying down" in the seclusion room all night, then alternately "awake, walking, quiet, and sitting during the following day." Patient #14 was seen by her physician at 10:30 am, but not released from seclusion until 12:15 pm, eleven hours after the start of seclusion.

Documentation reveals that no 15-minute observation found patient #14 threatening, combative, or aggressive. However, staff did not release her from seclusion. The RN documented that the primary psychiatrist who was not to come in until much later that day, would set the criterion for release. A physician face to face attempt was performed within one hour, yet the physician does not document patient behaviors, or if patient #14 could be released.

The hospital failed to discontinue seclusion at the earliest possible time, thus failing to honor patient #14 ' s right to be free of seclusion.

Based on an onsite investigation in which policy and procedure, interviews and 15 patient records were reviewed, patient #14 did not receive appropriate monitoring while in seclusion on 12/16/2010 as evidenced by:

Patient #14 is a 50-year-old female admitted on 12/14/2010 to the behavioral health unit from another hospital. Patient #14 had been showing bizarre behaviors in her home where she lives with her mother and daughters. She had not been sleeping or eating well, and was burning pictures and leaving lit papers around the house. She appeared suspicious of others, and unplugged phones and the microwave. At times, she would spit at, or hit family members. Patient #14 was observed to be responding to internal stimuli, and has a history of psychiatric hospitalization in her 20s. She received a diagnosis of Bipolar disorder, manic, severe, with psychotic features.

On 12/15/2010 at 11:45 pm, patient #14 came out of her room with a gait that appeared as though she might fall. Staff assisted her to a chair. Patient #14 expressed to staff that she felt "Afraid" and that "My legs feel heavy." When asked if she wanted to sleep in the quiet room closer to the nursing station, patient #14 instead went back to her room. She came out again at 11:50 pm and reported she had "Bad thoughts." Staff prepared medication for her, but patient #14 abruptly went to the fire alarm, and pulled the alarm.

Patient #14 was asked to go to the Open Door Quiet Room, but refused and began running around the unit. On approach, she became combative. Security arrived on the unit and placed patient #14 in Locked Door Seclusion at 1:10 am. A nursing initiation note of 12/16 at 2:16 am states criteria for restraint/seclusion removal as, "Patient will have to be assessed by psychiatrist in am due to unpredictable behaviors she presents a danger to herself and other patients on the unit. The patient's doctor will need to evaluate what criteria pt. needs to exhibit to be released."

RN fifteen minute monitoring of patient #14 beginning on 12/16/2010 at 1:15 am is not documented until the following day, starting on 12/17 at 10:17 pm. Likewise, all 15-minute monitoring is done the following day until 12/16/2010 at 8:30 am which is entered on 12/16/2010 at 12 pm. The record reveals that 15-minute flows are not documented as they happen, but may have hours or a day between when the observation is made, and when they are documented.

A psychiatry note of 2:20 am states "Pt. in locked door seclusion, no evidence of injury or distress. " The note addresses the patient ' s immediate situation, and her medical condition, but does not address the patient behavior, immediate reaction, or the need to continue the intervention.

A nursing note at 3 am states in part, "When patient was told that she had to go into the QR (quiet room, patient became combative and aggressive. Patient required hands on by the 3 security guards to get patient on the bed. Patient did calm down and was then released when she promised she would not struggle with staff. Patient agreed to received a prn Zyprexa 5 mg IM was administered at 0110. Dr. ___ was called for an order at 0115. Dr. ___saw the patient at 0210. Patient has been given water and has not been a management problem since being in LDS (locked door seclusion). The patient's behavior was unwarranted and unpredictable " ... " The patient will continue in LDS until Dr. ___ sees the patients in the am and evaluates if the patient can be on the unit safely."

Patient #14 is documented on the 15-minute flows as "lying down" in the seclusion room all night, then alternately "awake, walking, quiet, and sitting during the day." Patient #14 was seen by her physician at 10:30 am, and released from seclusion at 12:15 pm, eleven hours after the start of seclusion.

Documentation reveals that no 15-minute observation found patient #14 threatening, combative, or aggressive. However, staff did not release her from seclusion, as the RN documentation the physician would set the criterion for release. A physician saw patient #14 within one hour, yet the physician did not document patient behaviors, or if she should be released. Finally, nursing documents that staff would keep patient #14 in seclusion until she was assessed by her physician in the morning.

The hospital states that physicians must be aware of the hospital policy for seclusion and restraint (S/R). Physicians also receive newsletters which update them on S/R periodically. Psychiatrists received annual training in S/R. Nursing staff are trained for seclusion and restraint at orientation, then every two years, and do not currently receive training for face-to-face assessments. Mental health workers are trained to observe patients in seclusion and restraint only.

Employee files indicate that staff do receive training in seclusion and restraint. However, documentation reveals a lack of practical application of S/R monitoring and documentation at the physician, nurse, and mental health worker levels.

Based on an onsite investigation in which policy and procedure, interviews and 15 patient records were reviewed, patient ' s #12, 13, 14, 15 did not receive appropriate face-to-face assessments as evidenced by:

Patient #12 is a 28-year-old mentally retarded female who presented to the ED on 12/27/2010 after becoming agitated in her group home where she began to spit on persons there, and began throwing things. Patient #12 has a history of seizures and mental retardation. On initial assessment by the physician, she had pressured speech, and was not redirectable when she continued to throw things, and cursed at staff. An order of 12/28 at 9 am states Protect from injury to self and others, Seclusion.

Seclusion was initiated at 8:45 am with a release criteria of "Patient will be calm and redirectable." From 9:10 am, until 10:22 am, with one exception, patient #2 was quiet and eating breakfast or lying down. At 10:22 am, she was released from seclusion when she fell asleep. A physician wrote an order for a psychiatric consultation at 8:42 am. No face to face appears in the record. Patient #12 was examined at 1:15 pm, and discharged back to her group home.

Patient #13 is a 30-year-old female, emergency petitioned by her mother secondary to manic behaviors. Patient #13 had new medication that was not working for her. Patient #13 was taken to the hospital where she was assessed as agitated, manic, and psychotic. She was admitted 2/9/2011 to the behavioral health unit with a diagnosis of Bipolar Disorder.

On 2/11/2011 at 9:30 am, patient #13 was placed in 4-point restraint due to combative behavior. By 10:30, patient #13 was documented as "Sleeping." At 11:30 am, restraints were removed, and patient #13 was placed in open-door seclusion until 1 pm.

A 2/11 order for restraint at 9:35 am reveals a hand written physician memo in the margin of the order, that patient #13 "Was seen at 9:35 am." No documentation of face-to-face findings is noted.

Patient #14 is a 50-year-old female admitted on 12/14/2010 to the behavioral health unit from another hospital. Patient #14 had been showing bizarre behaviors in her home where she lives with her mother and daughters. She had not been sleeping or eating well, and was burning pictures and leaving lit papers around the house. She appeared suspicious of others, and unplugged phones and the microwave. At times, she would spit at, or hit family members. Patient #14 was observed to be responding to internal stimuli, and has a history of psychiatric hospitalization in her 20s. She received a diagnosis of Bipolar disorder, manic, severe, with psychotic features.

On 12/15/2010 at 11:45 pm, patient #14 came out of her room with a gait that appeared as though she might fall. Staff assisted her to a chair. Patient #14 expressed to staff that she felt "Afraid" and that, "My legs feel heavy." When asked if she wanted to sleep in the quiet room closer to the nursing station, patient #14 instead went back to her room. She came out again at 11:50 pm and reported she had "Bad thoughts." Staff prepared medication for her, but patient #14 abruptly went to the fire alarm, and pulled the alarm.

Patient #14 was asked to go to the Open Door Quiet Room, but refused and began running around the unit. On approach, she became combative. Security arrived on the unit and placed patient #14 in Locked Door Seclusion at 1:10 am. A nursing initiation note of 12/16 at 2:16 am states criteria for restraint/seclusion removal as "Patient will have to be assessed by psychiatrist in am due to unpredictable behaviors she presents a danger to herself and other patients on the unit. The patient's doctor will need to evaluate what criteria pt. needs to exhibit to be released."

A psychiatry note of 2:20 am states "Pt. in locked door seclusion, no evidence of injury or distress." The note addresses the patient ' s immediate situation, and her medical condition, but does not address the patient behavior, immediate reaction, or the need to continue the intervention.

A nursing note at 3 am states in part, "When patient was told that she had to go into the QR (quiet room, patient became combative and aggressive. Patient required hands on by the 3 security guards to get patient on the bed. Patient did calm down and was then released when she promised she would not struggle with staff. Patient agreed to received a prn Zyprexa 5 mg IM was administered at 0110. Dr. ___ was called for an order at 0115. Dr. ___saw the patient at 0210. Patient has been given water and has not been a management problem since being in LDS (locked door seclusion). " The patient ' s behavior was unwarranted and unpredictable " ... " The patient will continue in LDS until Dr. ___ sees the patients in the am and evaluates if the patient can be on the unit safely."

Patient #14 is documented on the 15-minute flows as "lying down" in the seclusion room all night, then alternately " awake, walking, quiet, and sitting during the day. Patient #14 was seen by her physician at 10:30 am, and released from seclusion at 12:15 pm, eleven hours following the start of seclusion.

Documentation reveals no 15-minute observation found patient #14 threatening, combative, or aggressive. However, staff did not release her from seclusion, since the RN documented the physician would set the criterion for release. One physician saw patient #14 within one hour, yet the physician did not document patient behaviors, or if she should be released, and nursing continued to document that staff would keep patient #14 in seclusion until she was assessed by her physician in the morning.

The hospital failed to perform an appropriate face to face assessment which may have found patient #14 ready to come out of seclusion.

Patient #15 is a 25-year-old male with a history of Bipolar disorder who was brought to the ED on 1/4/2011 by police on emergency petition after becoming threatening to his mother, and thinking she was a demon. Patient #15 had some medication changes, and had been noncompliant to some degree with taking them. He had not eaten for 10-days, and had been only drinking energy drinks. Patient #15 was hearing voices, was paranoid, and referring to himself by another name. He was admitted to the behavioral health unit.

On 1/7/2011, patient #15 became resistant to staff direction to remain clothed. Patient #15 came out on the unit naked, and when redirected, became hostile, agitated, and would not take redirection. An unsigned telephone order for 11:45 am appears in the record. Patient #15 was placed in seclusion at 11:45 am where he received Zyprexa 5 mg, and ativan 1 mg IM in addition to Depakote 250 mg by mouth. Patient #15 initially continued to disrobe, remained irritable and appeared to be responding to internal stimuli. A note entitled, " Attending Psychiatrist Progress Note " of 7/1/2011 at 10 am, shows an untimed addendum which states, " Pt. had to be placed in seclusion- agitated. " At 1 pm, patient #15 is noted to be sleeping which continued until 3:45 pm. At 4 pm, seclusion was discontinued, and patient #15 stated he did not remember taking off his clothing. From 1 pm until his release at 4 pm, patient #15 was noted to be sleeping. No face to face is noted in the record for this seclusion.

Seclusion was initiated again at 4:45 pm, due to patient #15 standing at the door of the psychiatrist office and refusing to leave, then becoming verbally abusive and threatening to staff and the psychiatrist. Patient #15 was noted to be yelling and threatening until 6 pm, and then is noted as lying down. Patient #5 was pacing and appeared to be responding to internal stimuli until 9:15 when he is noted " awake, pacing and quiet. At 9:30 pm, he was released from seclusion. An unsigned order for 8:15 pm appears in the record.

Based on an onsite investigation in which policy and procedure, interviews and 15 patient records were reviewed, it was determined that:
1) Patients #4, and #6 and #7 had late discharge summaries
2) Patients #14 and #15 had unsigned telephone orders.

The findings include:

Patient #4 was discharged on 12/10/2010. However, the discharge summary was completed and signed on 1/17/2010 at 12:38 am.

Patient #6 was discharged on 12/3/2010. However, no discharge summary was completed and signed until 2/8/2011.

Patient #7 was discharged on 12/5/2010. However, no discharge summary was completed and signed until 1/31/2011.

Patient #14's record contains: five (5) an unsigned telephone orders as follows:
1) Seclusion order of 12/16/2010 at 0530
2) Routine observation order of 12/17 at 1030
3) Vitals order of 12/17 at 1755
4) Lab orders on 12/18 at 0410
5) EKG order 12/18 at 0325

Patient #15's record contains a renewal of seclusion orders on 1/7/2011 at 1515 and 2015 which are unsigned.