HospitalInspections.org

Based on a review of clinical records, review of facility policies, hospital documentation, and interviews with facility personnel, the hospital failed to protect and promote the rights of thirteen (13) patients (Patient #1, 23, 34, 35, 36, 37, 38, 40, 41, 42, 43, 44, and 46).


The facility failed to ensure for twelve (12) patients (23, 34, 35, 36, 37, 38, 40, 41, 42, 43, 44, and 46) that restraints were instituted based on a comprehensive assessment of the patient, that alternatives were tried and documented in the medical record prior to utilization of restraints, least restrictive devices were utilized, and that patients were removed from restraints at the earliest possible time.

For one patient (Patient #1) the patient was subdued and placed in handcuffs by the hospital's security staff, although regulation identified that the use of such devices are considered a law enforcement restraint. The facility failed to ensure the Handcuff policy was in accordance with State and/or Federal Regulations.

Cross Reference to A 130, 154, 160, 164, 165, 169, 174, and 185.

Based on a review of the clinical record, review of the policy, and interview, the facility failed to ensure that one patient (#27) was included in the discharge plan and/or received comprehensive discharge instructions. The finding includes the following:

1. Review of the clinical record identified that Patient #27 was brought to the Emergency Department (ED) by police on 4/18/11 at 7:28 PM, after a domestic dispute. The patient had a past medical history of Bipolar diagnosis. The record identified that the patient was evaluated at triage and admitted into the ED Behavioral Health unit. Once in the unit, the patient refused to remove clothing in accordance with hospital policy. The patient became aggressive and combative (kicked security staff). The physician was notified. The review of systems completed by the physician were unremarkable with a diagnosis of alcohol intoxication. The local police were called as the patient continued with the aggressive behaviors. The patient was discharged into police custody at 8:10 PM in excellent condition. The discharge instructions provided to Patient #27 identified under the physician instruction/diagnosis section, "go directly to jail". The discharge instructions failed to include diagnosis, treatment rendered, or any pertinent follow-up instructions. Although the physician and the nurse signed these instructions, the patient didn't sign the record in accordance with hospital policy. The facility failed to include the patient in the discharge plan and/or develop a comprehensive individualized discharge plan that addressed the patient's diagnosis and/or alcohol use.

Review of the facility policy directed that each patient seen in the ED shall be given a written patient instruction sheet. The instruction sheet must exhibit documentation of all printed instruction sheets given to the patient and documentation of the nurse's instruction if applicable, the physician's instructions for aftercare and the patient's signature.

Based on a review of clinical records, policy review and interview, the facility failed to ensure that one patient (#1) was appropriately restrained based upon an individualized assessment of the patient. The finding includes the following:

1. Review of a triage form time stamped and dated 5/1/11 at 12:37 AM identified a handwritten first name of an "individual" (Patient #1) who presented to the ED. Review of the triage form and interview with Greeter #1 on 5/16/11 at 7:40 AM identified that when this patient entered the Emergency Room (ED) he/she asked "How can I help you?". Patient #1 responded "headache" and provided his/her first name, however, was unable to provide his/her last name and date of birth. Greeter #1 stated that when he/she asked the patient a second time for his/her last name, the patient yelled profanities, as Patient #1 leaned in towards him/her (the greeter) throwing his/her hands up. As Greeter #1 utilized the desk phone to call security, Security Guard #1 rounded the corner of the ED desk.
Interview with Security Guard #1 on 5/16/11 at 9:15 AM stated that he/she was assigned the post in the ED on 5/1/11. Security Guard #1 stated Greeter #1 had called security just as he/she was heading back to the triage desk and he/she observed an "irate person" who was yelling and using foul language. Security Guard #1 requested him/her to "stop yelling" and then asked the patient to leave, who replied, "make me". Security Guard #1 stated that he/she approached the patient and subsequently restrained the patient with the assistance of Security Guard # 2 in a take-down. Security Guard #3 was summoned to the ED for assistance and immediately applied handcuffs while Guard #1 and #2 held the patient down. Patient #1 was assisted to a standing position and walked to the side room and placed in a chair under the supervision of Security Guards #1, #2, and #3 to await police arrival. Security Guard #1 stated that the cuffs were switched out by the police without incident and Patient #1 was subsequently removed from the ED by police and placed in the police cruiser on hospital property.
The facility failed to ensure that security staff requested direction from nursing and/or medical personnel and that an appropriate restraint was utilized.

Interview with RN #1 on 5/3/11 at 10:15 AM stated while triaging a child, he/she heard someone yell profanities. RN #1 instructed Greeter #1 to call security, while continuing to triage other patients. RN #1 stated that she further instructed the Greeter to "call the police". RN #1 failed to intervene when Patient #1 was subdued and placed in handcuffs by Security staff and/or notify the physician and charge nurse of the situation in the waiting room. Although the patient remained in handcuffs, staff failed to assess the patient.

Interview with MD #1 on 5/18/11 at 12:00 PM stated that he/she first became aware of Patient #1 when brought into the trauma room pulseless and unresponsive on 5/1/11 at 1:02 AM.
Interview with the Director of the ED on 5/18/11 stated that Security Staff should take direction from nursing staff.
Interview with the Director of Security on 5/19/11 at 9:30 AM identified that Security Staff should rely on nursing for guidance.

Review of "Handcuff" policy reflected that handcuffs will be issued to each security officer and are only to be used when absolutely necessary. The policy failed to include all elements required for restraints implementation including but not limited to an individualized assessment of the patient, alternative measures tried, and least restrictive device. The policy failed to direct the need for medical personnel involvement to ensure the safety and well being of the patient. Interview with the Director of Security on 5/3/11 at 11:40 AM stated that Security Guards may purchase and carry handcuffs if they choose as handcuff application was part security guard training.

Review of the "Restraint" policy identified that the use of restraints is limited to clinically appropriate and adequately justified situations. The policy failed to define or describe what constitutes an appropriate and/or justified situation.
The "restraint" policy further identified that restraint use should be based on a comprehensive assessment of the patient and should be implemented in the least restrictive manner. The facility policy failed to reflect that handcuffs should not be utilized to restrain a patient as, "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" in accordance with CMS regulation.

Based on review of clinical records, review of facility policy, and interview, for six (6) of twelve (12) patient's reviewed for restraints (Patients #23, 34, 36, 43, 44 and 46), the facility failed to conduct a comprehensive patient assessment to determine the need for other types of interventions before using a drug or medication as a restraint. The findings include the following:


1. Patient #23 presented to the ED with facial lacerations on 4/10/11 at 11:40 PM. The triage note identified that the patient was yelling and threatening (not described) with hospital security and local police were called. The patient was placed in handcuffs and sprayed with mace by the local police and once calm, was placed in a cubicle for evaluation. The clinical record reflected that staff administered Geodon (antipsychotic medication) 20 mg IM at 11:20 PM, Ativan (antianxiety) 2 mg at 11:18 PM and 12:25 AM, and Haldol (antipsychotic) 5 mg IM at 12:30 AM, absent of an individualized assessment and documentation of specific behaviors warranting chemical (medication) restraints. Although the facility documented (check-off box) the patient was provided with reality orientation, and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient.

Review of the special observation flow sheet identified that the patient was placed in four point restraints on 11:45 PM on 4/10/11 and remained in the four point restraints until 1:30 AM on 4/11/11. The facility administered chemical (medication) and physical restraints without conducting a comprehensive assessment of the patient including documentation of alternative measures tried and utilization of the least restrictive device possible.


2. Patient #34 was brought to the ED on 5/1/11 at 11:27 AM by police. The nurse's note dated 5/1/11 at 11:27 AM indicated that the patient was brought in by the police in handcuffs after attempting to hang him/herself. The record identified that the patient was removed from the handcuffs and placed in four point locked restraints for "safety". The patient received Haldol 5 mg IM at 11:30, Benadryl (sedative) 50 mg IM at 11:41 PM, and Ativan 1 mg IM at 11:52 PM "as ordered" The nursing note dated 5/2/11 at 3:45 AM indicated that the patient was "resting". Review of the restraint record indicated that during the period of 12:30 AM through 2:00 AM the patient remained in four point restraints for behaviors described as "restless (not described)". Although the facility documented (check-off box) the patient was provided with reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. The facility administered chemical (medication) and physical restraints without conducting a comprehensive assessment of the patient including documentation of alternative measures tried and specific behaviors that posed a risk to self/others that warranted the administration of chemical restraints.


3. Review of Patient #36's clinical record identified that the patient was dropped off at the ED on 5/12/11 at 11:32 PM with a right parietal laceration. Review of the restraint record indicated that the patient was placed in four point locked restraints at 11:35 PM for "spitting", "confusion" and "yelling out". At 11:42 PM, the patient received Haldol 10 mg IM at 11:42 PM, Ativan 2 mg IM, and Cogentin (anticholinergic) 1 mg IM. Although the facility documented (check-off box) the patient was provided with reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. The facility administered chemical (medication) and physical restraints without conducting a comprehensive assessment of the patient including documentation of alternative measures tried and specific behaviors that posed a risk to self/others that warranted the administration of chemical restraints.



4. Review of Patient #43's clinical record identified that the patient presented to the ED on 4/24/11 at 3:20 AM after a motor vehicle accident. The clinical record indicated that Ativan 2 mg IV, Haldol 5 mg IM, and Benadryl 50 mg IV were administered at 4:20 AM for "banging self on the side rail". A nurse's note dated 4/24/11 at 4:45 AM reflected that the patient awoke, had "attempted to get out of bed" and "remained agitated (not described)". The patient was consequently placed in four point locked leather restraints with a one to one sitter assigned. At 4:55 AM, the patient was described as "banging self into the side rails" with a posey vest restraint applied in addition to the four point restraints with an additional 2 mg of Ativan IV administered. At 5:05 AM, Geodon 5 mg IM was administered for agitation. Review of the physician's orders section of the restraint record identified orders for two restraints, four point locked restraints and a vest restraint. Although the facility documented (check-off box) the patient was provided with reality orientation, diversion and one to one intervention, the approaches failed to be specific to address the needs of the patient. The facility failed to ensure that comprehensive assessments of the patient were conducted that reflected the need for physical and chemical (medication) restraints, alternative measures documented (e.g. padded side rails, pain assessment, toileting needs) and descriptive behaviors that warranted the ongoing utilization of restraints.



5. Review of Patient #44's clinical record identified that the patient had been found walking on the street incoherently and brought to the ED on 4/19/11 at 3:50 PM. The triage note reflected that the patient was unresponsive in triage with Narcan administered. The patient responded, however, was disoriented, slurring words and combative (not described). The patient was placed in four point locked restraints and medicated with Ativan 2 mg IV at 4:00 PM, 4:15 PM and 4:20 PM. Although the facility documented (check-off box) the patient was provided with reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. Review of the restraint record indicated that the patient remained in restraints for the period of 4:00 PM on 4/19/11 through 9:00 AM on 4/20/11. The facility administered chemical (medication) and physical restraints without conducting a comprehensive assessment of the patient including documentation of alternative measures tried and specific behaviors that posed a risk to self/others that warranted the administration of chemical restraints.


6. Patient #46 presented to the ED on 3/17/11 stating that "people wanted to hurt him/her". Review of the restraint record reflected that the patient was placed in two point locked restraints at 2:50 PM for behaviors identified as "yelling but not combative". The clinical record identified that the patient received Haldol 5 mg IM, Ativan 1 mg IM, and Benadryl 50 mg by mouth at 3:00 PM for agitation (not described). The nurse's note dated 3/12/11 at 3:50 PM indicated that the patient was "sleeping". Although the facility documented (check-off box) the patient was provided with reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. The patient remained in two point locked restraints until 3:50 PM. Documented behaviors while restrained included "eating" and "resting calmly". The facility administered chemical (medication) and physical restraints without conducting a comprehensive assessment of the patient including documentation of alternative measures tried and specific behaviors that posed a risk to self/others that warranted the administration of chemical restraints.


Review of the restraint policy defined a chemical restraint as a drug used for the emergency control of behavior that is not part of the patients normal medication regime. The policy indicated that the decision to use restraints should be based on a comprehensive individualized assessment.

Based on a review of clinical records, review of facility policies, and interviews, for twelve (12) of twelve (12) patients reviewed for restraints (Patients #23, 34, 35, 36, 37, 38, 40, 41, 42, 43, 44, and 46), the facility failed to conduct a comprehensive patient assessment that demonstrated the need for restraints, documentation of patient specific alternatives tried and/or the rationale why less restrictive interventions were ineffective. The findings include the following:


1. Patient #23 presented to the ED with facial lacerations on 4/10/11 at 11:40 PM. The triage note identified that the patient was yelling and threatening (not described) with hospital security and local police were called. The patient was placed in handcuffs and sprayed with mace by the local police and once calm, was placed in a cubicle for evaluation. The clinical record reflected that staff administered Geodon (antipsychotic medication) 20 mg IM at 11:20 PM, Ativan (antianxiety) 2 mg at 11:18 PM and 12:25 AM, and Haldol (antipsychotic) 5 mg IM at 12:30 AM, absent of an individualized assessment and documentation of specific behaviors warranting restraints. Although the facility documented (check-off box) the patient was provided with reality orientation, and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. Review of the clinical record identified that the patient was placed in four point restraints on 11:45 PM on 4/10/11 for "agitation" (not described). The facility failed to ensure that restraints were implemented based on a comprehensive assessment of the patient, documentation of alternative measures tried prior to application of four point restraints and administration of chemical restraints, and utilization of the least restrictive device possible.



2. Patient #34 was brought to the ED on 5/1/11 at 11:27 AM by police. The nurse's note dated 5/1/11 at 11:27 AM indicated that the patient was brought in by the police in handcuffs after attempting to hang him/herself. The record identified that the patient was removed from the handcuffs and placed in four point locked restraints for "safety". The patient received Haldol 5 mg IM at 11:30, Benadryl (sedative) 50 mg IM at 11:41 PM, and Ativan 1 mg IM at 11:52 PM"as ordered". Although the facility documented (check-off box) the patient was provided with reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. The facility failed to ensure that restraints were implemented based on a comprehensive assessment of the patient, documentation of alternative measures tried prior to application of four point restraints and administration of chemical restraints, and utilization of the least restrictive device possible.


3. Patient #35 was brought to the ED by police on 5/15/11 at 4:45 PM after an attempt to hurt self. Review of the clinical record dated 5/14/11 at 5:40 PM reflected the patient was placed in four point locked leather restraints for "cursing and agitation" (not described). Although the facility documented (check-off box) the patient was provided with reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. The facility failed to ensure that restraints were implemented based on a comprehensive assessment of the patient, documentation of alternative measures tried prior to application of four point restraints, and utilization of the least restrictive device possible.


4. Review of Patient #36's clinical record identified that the patient was dropped off at the ED on 5/12/11 at 11:32 PM with a right parietal laceration. Review of the restraint record indicated that the patient was placed in four point locked restraints at 11:35 PM for "spitting", "confusion" and "yelling out". At 11:42 PM, the patient received Haldol 10 mg IM at 11:42 PM, Ativan 2 mg IM, and Cogentin (anticholinergic) 1 mg IM. Although the facility documented (check-off box) the patient was provided with reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. The facility failed to ensure that restraints were implemented based on a comprehensive assessment of the patient, documentation of alternative measures tried prior to application of four point restraints and chemical restraints, and utilization of the least restrictive device possible.




5. Patient #37 presented to the ED on 3/29/11 at 9:00 PM with a contusion above the left eye and alcohol use. Review of the clinical record identified that the patient was placed in four point locked restraints at 9:30 PM for "positive alcohol, threatening and combative (behavior not described)", behaviors. Although the facility documented (check-off box) the patient was provided with diversion, reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. The facility failed to ensure that restraints were implemented based on a comprehensive assessment of the patient, documentation of alternative measures tried prior to application of four point restraints, and utilization of the least restrictive device possible.


6. Patient #38 presented to the ED on 4/20/11 at 3:00 AM with "out of control" behaviors and trying to hit and kick staff. The nurse's note indicated that the patient was placed in four point locked restraints for "safety". Interventions attempted prior to initiation of restraints were not documented. The facility failed to document alternative measures tried prior to application of four point restraints and utilization of the least restrictive device possible.

7. Patient #40 presented to the ED on 4/12/11 at 3:53 AM stating he/she felt like he/she was on fire. The clinical record reflected that the patient was placed in four point locked restraints on 4/12/11 at 4:15 AM for "agitation and combative" behaviors not described. Although the facility documented (check-off box) the patient was provided with medication review and physiological assessment, the approaches failed to be specific to address the needs of the patient. At 5:00 AM, the patient was "restless" and at 5:15 AM, was "asleep". The patient remained asleep in four point restraints until 6:15 AM at which time the restraints were decreased to two point and the patient was in two point restraints until 6:45 AM. Review of the restraint record indicated that the initial physical and behavioral assessment and observation of correct applications had not been completed. Review of the nurse's notes failed to identify an assessment of the patient. Review of the clinical record and interview with the Director of the ED on 5/19/11 at 2:00 PM stated he/she was unable to locate the first page of notes that may reflect patient assessment. The facility failed to ensure that restraints were implemented based on a comprehensive assessment of the patient, documentation of alternative measures tried prior to application of four point restraints, and utilization of the least restrictive device possible.


8. Patient #41 was brought into the ED by the police on 3/23/11 at 11:50 PM after a fall and alcohol use. The nurse's note dated 3/24/11 at 12:10 AM reflected the patient was refusing to stay on the stretcher and almost fell three times. Subsequently, the patient was placed in four point locked restraints. Although the facility documented (check-off box) the patient was provided with diversion and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. The facility failed to ensure that restraints were implemented based on a comprehensive assessment of the patient, documentation of alternative measures tried prior to application of four point restraints, and utilization of the least restrictive device possible.



9. Patient #42 presented to the ED on 5/17/11 at 10:10 PM after experiencing a seizure. Review of a nurse's note dated 5/17/11 at 10:55 PM indicated that the patient was attempting to get out of bed and a vest restraint was applied. Although the facility documented (check-off box) the patient was provided with companionship, medication review, physiologic assessment, reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. The facility failed to ensure that restraints were implemented based on a comprehensive assessment of the patient, documentation of patient specific approaches tried prior to application of a vest restraint, and utilization of the least restrictive device possible.



10. Review of Patient #43's clinical record identified that the patient presented to the ED on 4/24/11 at 3:20 AM after a motor vehicle accident. The clinical record indicated that Ativan 2 mg IV, Haldol 5 mg IM, and Benadryl 50 mg IV were administered at 4:20 AM for "banging self on the side rail". A nurse's note dated 4/24/11 at 4:45 AM reflected that the patient awoke, had "attempted to get out of bed" and "remained agitated (not described)". The patient was consequently placed in four point locked leather restraints with a one to one sitter assigned. At 4:55 AM, the patient was described as "banging self into the side rails" with a posey vest restraint applied in addition to the four point restraints with an additional 2 mg of Ativan IV administered. At 5:05 AM, Geodon 5 mg IM was administered for agitation. Review of the physician's orders section of the restraint record identified orders for two restraints, four point locked restraints and a vest restraint. Although the facility documented (check-off box) the patient was provided with reality orientation, diversion and one to one intervention, the approaches failed to be specific to address the needs of the patient. The facility failed to ensure that restraints were implemented based on a comprehensive assessment of the patient, documentation of alternative measures tried prior to application of several types of restraints including chemical restraints, and utilization of the least restrictive device possible.




11. Review of Patient #44's clinical record identified that the patient had been found walking on the street incoherently and brought to the ED on 4/19/11 at 3:50 PM. The triage note reflected that the patient was unresponsive in triage with Narcan administered. The patient responded, however, was disoriented, slurring words and combative (not described). The patient was placed in four point locked restraints and medicated with Ativan 2 mg IV at 4:00 PM, 4:15 PM and 4:20 PM. Although the facility documented (check-off box) the patient was provided with reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. The facility failed to ensure that restraints were implemented based on a comprehensive assessment of the patient, documentation of alternative measures tried prior to application of four point restraints and chemical restraints, and utilization of the least restrictive device possible.




12. Patient #46 presented to the ED on 3/17/11 stating that "people wanted to hurt him/her". Review of the restraint record reflected that the patient was placed in two point locked restraints at 2:50 PM for behaviors identified as "yelling but not combative". The clinical record identified that the patient received Haldol 5 mg IM, Ativan 1 mg IM, and Benadryl 50 mg by mouth at 3:00 PM for agitation. Although the facility documented (check-off box) the patient was provided with reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. The facility failed to ensure that restraints were implemented based on a comprehensive assessment of the patient, documentation of alternative measures tried prior to application of two point restraints and chemical restraints, and utilization of the least restrictive device possible.



Review of the restraint policy and interviews with the Director of the ED and the Nurse Educator on 5/19/11 at 11:00 AM identified that the use of restraints is limited to clinically appropriate and adequately justified situations. The policy failed to define or describe what constitutes an appropriate and/or justified situation. Restraint use should be based on a comprehensive assessment of the patient and should be implemented in the least restrictive manner. The Director stated that all staff are educated annually on the use of restraints and the restraint policy.

Further review of the policy indicated that behavioral restraints should be used only in an emergency situation. An emergency is defined as a situation where the patients behavior is violent or aggressive and where the behavior presents an immediate and serious danger to the safety of the patients, staff and other individuals and/or when non physical interventions are not viable. The decision to use restraints is driven not by diagnosis but by a comprehensive assessment.

Based on a review of the clinical record and review of the facility policy for one (1) of twelve (12) records reviewed (Patient #42) the facility failed to ensure that restraint orders clearly directed the use of one type of restraint. The finding includes the following:

Patient #42 presented to the ED on 5/17/11 at 10:10 PM after experiencing a seizure. Review of a nurse's note dated 5/17/11 at 10:55 PM indicated that the patient was attempting to get out of bed with a vest restraint applied. A physician's order dated 5/17/11 at 11:00 PM directed the use of a vest restraint and two limb soft restraints. A note at 11:30 PM indicated that the patient was agitated, pulling at lines with soft restraints applied. Documentation failed to reflect whether the vest restraint was removed when soft restraints were applied. A nurse's note identified that the patient was sleeping and the wrist restraints were removed at 1:15 AM, however, documentation reflected that the vest restraint was in place. The facility failed to ensure that the physician's order provided clear direction for utilization of restraints.

Review of restraint policy identified that the physician's order shall include the reason for use and the specific type of restraint required (i.e. vest vs. extremity restraints).

Based on a review of clinical records, review of policies, and interviews, for eleven (11) of twelve (12) patients reviewed for restraints (Patients #23, 34, 35, 36, 37, 38, 40, 42, 43, 44, and 46), the facility failed to ensure reduction or elimination of restraints at the earliest possible time. The findings include the following:

1. Patient #23 presented to the ED with facial lacerations on 4/10/11 at 11:40 PM. The triage note identified that the patient was yelling and threatening (not described) with hospital security and local police were called. The patient was placed in handcuffs and sprayed with mace by the local police and once calm, was placed in a cubicle for evaluation. Review of the clinical record identified that the patient was placed in four point restraints on 11:45 PM on 4/10/11 for "agitation" (not described). The clinical record reflected that the patient remained in four point restraints during the period of 11:45 PM through 1:30 am on 4/11/11 for "agitated and/or screaming". A nurse's note dated 4/11/11 at 1:30 AM identified the patient was sleeping soundly and in two point restraints per police dept. request because patient was a flight risk. Review of the restraint orders dated 4/11/11 at 1:45 AM indicated an order for 2 point restraints and that the reason for the restraints was identified as police request. The facility failed to ensure the restraints were removed at the earliest possible time.

In addition, although review of the restraint record indicated that at 2:45 AM through 3:30 AM the patient was screaming, the special observation flow sheet indicated that the patient was in bed asleep. The clinical record reflected inconsistent documentation.


2. Patient #34 was brought to the ED on 5/1/11 at 11:27 AM by police. The nurse's note dated 5/1/11 at 11:27 AM indicated that the patient was brought in by the police in handcuffs after attempting to hang him/herself and the patient was placed in four point locked restraints for "safety". Review of the restraint record indicated that during the period of 12:30 AM through 2:00 AM the patient remained in four point restraints for "restless" behavior. The restraint record indicated that at 2:00 AM the patient was decreased to two point restraints and remained in two point until the restraints were removed at 3:45 AM. The facility failed to ensure that the restraints were discontinued at the earliest possible time.



3. Patient #35 brought to the ED by police on 5/15/11 at 4:45 PM after an attempt to hurt self. Review of the clinical record dated 5/14/11 at 5:40 PM reflected the patient was placed in four point locked leather restraints for "cursing and agitation" (not described). The documentation identified that the patient was described as "calm" or "restless" at 6:15 PM, restraints were not removed until 7:30 PM. The facility failed to ensure that restraints were removed at the earliest possible time.


4. Review of Patient #36's clinical record identified that the patient was dropped off at the ED on 5/12/11 at 11:32 PM with a right parietal laceration. Review of the clinical record indicated that the patient was placed in four point locked restraints at 11:35 PM for "spitting", "confusion" and "yelling out". At 12:00 AM on 5/14/11, the patient was "calmer/quiet", however, the restraints were not removed until 12:30 AM. Athough Patient #36 remained on constant observation by facility staff and that a check mark appeared in the assessment box of the restraint monitoring form every hour, no attempts to release any part of the four point restraint was evident. The facility failed to ensure that restraints were removed at the earliest possible time.



5. Patient #37 presented to the ED on 3/29/11 at 9:00 PM with a contusion above the left eye and alcohol use. Review of the clinical record identified that the patient was placed in four point locked restraints at 9:30 PM for "positive alcohol, threatening and combative (behavior not described)", behaviors. Review of the monitoring record reflected that during the period of 11:00 PM through 12:30 AM, the patient was calm, awake, quiet, and/or sleeping. The facility failed to ensure that the restraints were discontinued at the earliest possible time.


6. Patient #38 presented to the ED on 4/20/11 at 3:00 AM with "out of control" behaviors and trying to hit and kick staff. The nurse's note indicated that the patient was placed in four point locked restraints. During the period of 3:35 AM through 4:15 AM the patient was yelling, agitated and/or sleeping. The facility failed to ensure that the restraints were reduced at the earliest possible time.

7. Patient #40 presented to the ED on 4/12/11 at 3:53 AM stating he/she felt like he/she was on fire. The restraint record indicated that the patient was placed in four point locked restraints on 4/12/11 at 4:15 AM for identified behaviors of "agitation" and "combative". The restraint record identified that at 5:00 AM the patient was restless and asleep at 5:15 AM. The patient remained asleep in four point restraints until 6:15 AM and in two point restraints until 6:45 AM. The facility failed to ensure that the restraints were reduced at the earliest possible time.

8. Patient #42 presented to the ED on 5/17/11 at 10:10 PM after experiencing a seizure. Review of the ED nurse's note dated 5/17/11 at 10:55 PM indicated that the patient was attempting to get out of bed and a vest restraint was applied. The note at 11:30 PM indicated that the patient was agitated pulling at lines and bilateral soft wrist restraints were applied. The restraint record identified that at 1:00 AM the patient was sleeping and that the restraints in use were changed from bilateral wrists to a vest restraint. Review of the restraint record indicated for the period of 1:15 AM through 11:00 AM the patient was quiet/ sleeping and remained in a vest restraint. The facility failed to ensure that the restraints were reduced at the earliest possible time.


9. Review of Patient #43's clinical record identified that the patient presented to the ED on 4/24/11 at 3:20 AM after a motor vehicle accident. A nurse's note dated 4/24/11 at 4:45 AM reflected that the patient awoke, had "attempted to get out of bed" and "remained agitated (not described)". The patient was consequently placed in four point locked leather restraints with a one to one sitter assigned. At 4:55 AM, the patient was described as "banging self into the side rails" with a posey vest restraint applied in addition to the four point restraints. The flow sheet indicated that at 9:00 AM, 9:15 AM, and 9:30 AM the patient was calmer and/or sleeping. The 9:45 AM entry indicated that the patient was "combative" and for the period of 10:00 AM though 10:45 AM the monitoring indicated that the patient was sleeping. The facility failed to discontinue the use of restraints at the earliest possible time.

10. Review of Patient #44's clinical record identified that the patient had been found walking on the street incoherently and brought to the ED on 4/19/11 at 3:50 PM. The triage note reflected that the patient was unresponsive in triage with Narcan administered. The patient responded, however, was disoriented, slurring words and combative (not described). The patient was placed in four point locked restraints at 4:00 PM. Review of the clinical record dated 4/19/11 during the period of 6:30 PM intermittently through 4/20/11 at 12:15 PM, the patient was observed to be sleeping, however, remained in restraints. The patient remained in restraints for ten hours with no behaviors exhibited. The facility failed to discontinue the use of restraints at the earliest possible time.


11. Patient #46 presented to the ED on 3/17/11 stating that "people wanted to hurt him/her". Review of the restraint record reflected that the patient was placed in two point locked restraints at 2:50 PM for behaviors identified as "yelling but not combative". The clinical record indicated that during the period of 3:15 PM-3:45 PM, the patient required food and/or was observed to be "sleeping". The facility failed to discontinue the use of restraints at the earliest possible time.


Review of the restraint policy indicated that the use of restraints is limited to clinically appropriate and adequately justified situations. The use of restraints should be based on a comprehensive assessment of the patient and should be the least restrictive and discontinued at the earliest possible time.

Based on a review of clinical records, review of policies, and staff interview for twelve (12) of twelve (12) patients reviewed for restraints (Patient #23, 34, 35, 36, 37, 38, 40, 41, 42, 43, 44, and 46), the medical record failed to reflect specific patient behaviors requiring restraint use. The findings include the following:


1. Patient #23 presented to the ED with facial lacerations on 4/10/11 at 11:40 PM. The triage note identified that the patient was yelling and threatening (not described) with hospital security and local police were called. The patient was placed in handcuffs and sprayed with mace by the local police and once calm, was placed in a cubicle for evaluation. The clinical record reflected that staff administered Geodon (antipsychotic medication) 20 mg IM at 11:20 PM, Ativan (antianxiety) 2 mg at 11:18 PM and 12:25 AM, and Haldol (antipsychotic) 5 mg IM at 12:30 AM, absent of an individualized assessment and documentation of specific behaviors warranting restraints. Although the facility documented (check-off box) the patient was provided with reality orientation, and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient.

Review of the special observation flow sheet identified that the patient was placed in four point restraints on 11:45 PM on 4/10/11 and remained in the four point restraints until 1:30 AM on 4/11/11. The facility failed to document a description of the patient's behavior that warranted the implementation and ongoing need for restraints.





2. Patient #34 was brought to the ED on 5/1/11 at 11:27 AM by police. The nurse's note dated 5/1/11 at 11:27 AM indicated that the patient was brought in by the police in handcuffs after attempting to hang him/herself. The record identified that the patient was removed from the handcuffs and placed in four point locked restraints for "safety". The patient received Haldol 5 mg IM at 11:30, Benadryl (sedative) 50 mg IM at 11:41 PM, and Ativan 1 mg IM at 11:52 PM "as ordered" The nursing note dated 5/2/11 at 3:45 AM indicated that the patient was "resting". Review of the restraint record indicated that during the period of 12:30 AM through 2:00 AM the patient remained in four point restraints for behaviors described as "restless (not described)". Although the facility documented (check-off box) the patient was provided with reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. The facility failed to document a description of the patient's behavior that warranted the implementation and ongoing need for restraints.




3. Patient #35 brought to the ED by police on 5/15/11 at 4:45 PM after an attempt to hurt self. Review of the clinical record dated 5/14/11 at 5:40 PM reflected the patient was placed in four point locked leather restraints for "cursing and agitation"(not described). Although the facility documented (check-off box) the patient was provided with reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. The documentation identified that the patient was described as "calm" or "restless" as 6:15 PM, restraints were not removed until 7:30 PM. Although Patient #35 remained on constant observation by facility staff and that a check mark appeared in the assessment box of the restraint monitoring form every hour, no attempts to release any part of the four point restraint was evident. The facility failed to document a description of the patient's behavior that warranted the implementation and ongoing need for restraints.




4. Review of Patient #36's clinical record identified that the patient was dropped off at the ED on 5/12/11 at 11:32 PM with a right parietal laceration. Review of the restraint record indicated that the patient was placed in four point locked restraints at 11:35 PM for "spitting", "confusion" and "yelling out" behaviors not described. At 11:42 PM, the patient received Haldol 10 mg IM at 11:42 PM, Ativan 2 mg IM, and Cogentin (anticholinergic) 1 mg IM. Although the facility documented (check-off box) the patient was provided with reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient.

The restraint record entry at 12:00 AM on 5/14/11 reflected that the patient was "calmer/quiet", the restraints were not removed until 12:30 AM. The facility failed to document a description of the patient's behavior that warranted the implementation and ongoing need for restraints.



5. Patient # 37 presented to the ED on 3/29/11 at 9:00 PM with a contusion above the left eye and alcohol use. Review of the clinical record identified that the patient was placed in four point locked restraints at 9:30 PM for "positive alcohol, threatening and combative (behavior not described)", behaviors. Although the facility documented (check-off box) the patient was provided with diversion, reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. The record indicated that although during the period of 11:00 PM through 12:30 AM the patient was described as "calm, awake, quiet, and sleeping", the patient's restraints were not removed until 12:30 AM. The facility failed to document a description of the patient's behavior that warranted the implementation and ongoing need for restraints.




6. Patient #38 presented to the ED on 4/20/11 at 3:00 AM with "out of control" behaviors and trying to hit and kick staff. The nurse's note indicated that the patient was placed in four point locked restraints. Review of the restraint record failed to identify that alternatives had been attempted prior to the initiation of the four point restraints. For the period of 3:35 AM through 4:15 AM the patient was yelling, agitated (not described), or sleeping. The facility failed to document a description of the patient's behavior that warranted the implementation and ongoing need for restraints.




7. Patient #40 presented to the ED on 4/12/11 at 3:53 AM stating he/she felt like he/she was on fire. The clinical record reflected that the patient was placed in four point locked restraints on 4/12/11 at 4:15 AM for "agitation and combative" behaviors not described. Although the facility documented (check-off box) the patient was provided with medication review and physiological assessment, the approaches failed to be specific to address the needs of the patient. At 5:00 AM, the patient was "restless" and at 5:15 AM, was "asleep". The patient remained asleep in four point restraints until 6:15 AM at which time the restraints were decreased to two point restraints. The facility failed to document a description of the patient's behavior that warranted the implementation and ongoing need for restraints.



8. Patient #41 was brought into the ED by the police on 3/23/11 at 11:50 PM after a fall and alcohol use. The nurses note dated 3/24/11 at 12:10 AM indicated that the patient was refusing to stay on the stretcher and was placed in four point locked restraints. Review of the restraint record indicated that the patient was in four point restraints for the period of 12:55 AM through 3:40 AM for undescribed behaviors that included, "agitated and yelling". The facility failed to document a description of the patient's behavior that warranted the implementation and ongoing need for restraints.




9. Patient #42 presented to the ED on 5/17/11 at 10:10 PM after experiencing a seizure. Review of a nurse's note dated 5/17/11 at 10:55 PM indicated that the patient was "attempting to get out of bed" and a vest restraint was applied. Although the facility documented (check-off box) the patient was provided with companionship, medication review, physiologic assessment, reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. The facility failed to document a description of the patient's behavior that warranted the implementation and ongoing need for restraints.




10. Review of Patient #43's clinical record identified that the patient presented to the ED on 4/24/11 at 3:20 AM after a motor vehicle accident. The clinical record indicated that Ativan 2 mg IV, Haldol 5 mg IM, and Benadryl 50 mg IV were administered at 4:20 AM for "banging self on the side rail". A nurse's note dated 4/24/11 at 4:45 AM reflected that the patient awoke, had "attempted to get out of bed" and "remained "agitated" (not described). The patient was consequently placed in four point locked leather restraints with a one to one sitter assigned. At 4:55 AM, the patient was described as "banging self into the side rails" with a posey vest restraint applied in addition to the four point restraints with an additional 2 mg of Ativan IV administered. At 5:05 AM, Geodon 5 mg IM was administered for agitation. Review of the physician's orders section of the restraint record identified orders for two restraints, four point locked restraints and a vest restraint. Although the facility documented (check-off box) the patient was provided with reality orientation, diversion and one to one intervention, the approaches failed to be specific to address the needs of the patient. The restraint record indicated that during the period of 4:55 AM through 10:45 AM the patient was "yelling", "combative", "uncooperative", "thrashing", "calm" and/or "sleeping". The facility failed to document a description of the patient's behavior that warranted the implementation and ongoing need for restraints.




11. Review of Patient #44's clinical record identified that the patient had been found walking on the street incoherently and brought to the ED on 4/19/11 at 3:50 PM. The triage note reflected that the patient was unresponsive in triage with Narcan administered. The patient responded, however, was disoriented, slurring words and combative (not described). The patient was placed in four point locked restraints and medicated with Ativan 2 mg IV at 4:00 PM, 4:15 PM and 4:20 PM. Although the facility documented (check-off box) the patient was provided with reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. Review of the restraint record indicated that the patient remained in restraints for the period of 4:00 PM on 4/19/11 through 9:00 AM on 4/20/11. The facility failed to document a description of the patient's behavior that warranted the implementation and ongoing need for restraints.




12. Patient #46 presented to the ED on 3/17/11 stating that "people wanted to hurt him/her". Review of the restraint record reflected that the patient was placed in two point locked restraints at 2:50 PM for behaviors identified as "yelling but not combative". The clinical record identified that the patient received Haldol 5 mg IM, Ativan 1 mg IM, and Benadryl 50 mg by mouth at 3:00 PM for agitation. The nurse's note dated 3/12/11 at 3:50 PM indicated that the patient was "sleeping". Although the facility documented (check-off box) the patient was provided with reality orientation and one to one verbal intervention, the approaches failed to be specific to address the needs of the patient. The patient remained in two point locked restraints until 3:50 PM. Documented behaviors while restrained included "eating" and "resting calmly". The facility failed to document a description of the patient's behavior that warranted the implementation and ongoing need for restraints.




Review of the restraint policy and interviews with the Director of the ED and the Nurse Educator on 5/19/11 at 11:00 AM identified that the use of restraints is limited to clinically appropriate and adequately justified situations. The policy failed to define or describe what constitutes an appropriate and/or justified situation. Restraint use should be based on a comprehensive assessment of the patient and should be implemented in the least restrictive manner.

Further review of the policy indicated that behavioral restraints should be used only in an emergency situation. An emergency is defined as a situation where the patients behavior is violent or aggressive and where the behavior presents an immediate and serious danger to the safety of the patients, staff and other individuals and/or when non physical interventions are not viable. The decision to use restraints is driven not by diagnosis but by a comprehensive assessment.

Based on a review of 12 clinical records, hospital policies/procedures, hospital documentation, and interviews with hospital personnel, the hospital's Quality Assessment and Performance Improvement program failed to include a comprehensive assessment of restraint utilization throughout the hospital including security polices pertaining to restraint application (e.g. handcuffs).


On October 2, 2009 the hospital was cited for failure to ensure that least restrictive restraints were utilized and/or that restraint reduction attempts were made. Although the hospital provided a plan to correct the deficient practice, subsequent visits conducted at the Hospital on 5/19/11 and 6/6/11 identified that the facility failed to maintain compliance with utilization of restraints.

Cross Reference A154, A160, A164, A169, A174, A185 and A310.

Based on a review of facility documentation and interviews, the facility failed to maintain an effective data driven quality assessment and performance improvement program for restraint utilization. The finding includes the following:

Review of the Quality Coordinating Committee minutes dated 11/09 identified that restraint utilization data had been collected with 100% of compliance noted with a plan to discuss the need to continue this quality project. Interview with the Director of the Emergency Department (ED) on 5/19/11 at 10:00 AM stated that once 100% compliance was achieved, the decision was made to stop reporting the restraint data to the Quality Coordinating Committee, however, the ED Director would still continue to audit 100% of the records of patients who utilized restraints.

Review of facility documentation and interview with the Director of the ED on 6/6/11 at 9:00 AM identified that the ED Director or designee completes chart audits for all restraint use in the ED which includes the elements of the physician's order (type, duration, reason, date, time, signature, and order renewed according to policy) and nursing documentation (interventions attempted, procedure explained, initial application, and restraints applied, Q15 minute behavior assessments, restraint location, range of motion, circulation, vital sign monitoring, Q 2 hour activity, and discharge assessment).

Review of the restraint log also reviewed by the ED Director reflected information that included, the patients name, age, the shift restraints were applied, length of time in restraints, type of restraints, and behaviors requiring restraints. The Director stated that based on the audit results, staff were reeducated when non-compliance was identified.

Review of the auditing documentation and the "Adult Restraint Record" failed to identify that individualized patient assessments were conducted and ongoing while the patient remained in restraints including but not limited to least restrictive restraints and removed at the earliest time. In addition, behaviors exhibited by the patient were not descriptive and interventions attempted were not specific to the patient.

During the onsite visits, on 5/19/11 and 6/6/11, medical records were reviewed for restraint utilization. The facility failed to conduct individualized patient assessments that demonstrated the need for restraints, documentation of patient specific alternatives tried and/or the rationale why less restrictive interventions were ineffective, specific behaviors that warranted the implementation and ongoing need for restraints, restraint reduction or elimination of restraints at the earliest possible time, and physician orders that clearly defined restraint use.

Although the hospital completed chart audits to monitor compliance, the hospital failed to put effective systems in place that addressed the ongoing non-compliance issues.


Review of the "Restraint" policy identified that the use of restraints is limited to clinically appropriate and adequately justified situations. The policy failed to define or describe what constitutes an appropriate and/or justified situation.
The hospital utilized a "handcuff" policy despite the Federal Regulation that defines the use of handcuffs as, "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".

Cross reference A154, A160, A164, A169, A174, and A185.