HospitalInspections.org

Based on interview and record review, the hospital failed to discontinue restraints (leather cuffs applied around the patient's wrists and ankles and attached to a bed to restrict movement) at the earliest possible time for two of 15 sampled patients (13 and 14). Findings:

Patient 13 was admitted on 3/4/14 with a diagnosis of being a danger to self. The record was reviewed on 4/3/14. Nurses notes indicated restraints were applied to Patient 13's wrists and ankles on 3/5/14 at 4 p.m. for behaviors of agitation, restlessness, and verbal abusiveness presenting imminent risk of harm to self and others. Nursing notes further indicated Patient 13 was asleep from 5:30 p.m. to 6 p.m. on 3/5/14 but restraints were continued for "the presence of behavior that required restraint."

Patient 14 was admitted on 1/16/14 with a diagnosis of being a danger to self. The record was reviewed on 4/3/14. Nurses notes indicated restraints were applied to Patient 14's wrists and ankles on 1/20/14 at 4:30 p.m. for behaviors of agitation, restlessness, and hallucinations presenting imminent risk of harm to self and others. Further review of the nurses notes indicated Patient 14 was asleep from 10:45 p.m. to 11:15 p.m. on 1/20/14 but restraints were continued for "the presence of behavior that required restraint."

During an interview on 4/3/14 at 8:35 a.m., the director of nurses was asked to explain why Patients 13 and 14 continued to be on restraints while asleep. The director of nurses stated the restrains were continued for precautionary reasons.

On 4/3/14 a review of the 12/2013 hospital policy and procedure titled "Restraint and Seclusion" indicated "if a patient falls asleep while in restraints, at a minimum the restraints will be removed".

Based on interview and record review, the hospital failed to provide evidence a licensed independent practitioner (LIP, a person specially trained and qualified to assess the need for restraints) conducted a face-to-face evaluation within 1 hour after the initiation of restraints (leather cuffs applied around the patient's wrists and ankles and attached to a bed to restrict movement) for two of 15 sampled patients (7 and 15). Findings:

Patient 7 was admitted on 11/15/13 with a diagnosis of psychosis (mental illness). The record was reviewed on 4/3/14. Nursing notes indicated restraints were applied to Patient 7's wrists and ankles on 11/22/13 at 9:45 a.m. for behaviors of agitation, restlessness, and verbal abusiveness presenting imminent risk of harm to others. Nursing notes indicated a LIP conducted a face-to-face evaluation during the time the restrains were initiated. Further review of the medical record lacked evidence the said face-to-face evaluation was conducted by a LIP (the medical record did not contain the "One Hour Face to Face Evaluation" form required by the hospital).

Patient 15 was admitted on 1/14/14 with a diagnosis of psychosis and suicidal ideations. The record was reviewed on 4/3/14. Nursing notes indicated restraints were applied to Patient 15's wrists and ankles on 1/14/14 at 2:45 p.m. for behaviors of agitation, restlessness presenting imminent risk of harm to others. Nursing notes indicated a LIP conducted a face-to-face evaluation. Further review of the medical record lacked evidence the said face to face evaluation was conducted by a LIP (the medical record did not contain the "One Hour Face to Face Evaluation" form required by the hospital).

During an interview on 4/3/14 at 8:35 a.m., the director of nurses confirmed the medical records for Patient 7 and Patient 15 lacked the required documentation indicating a face-to-face evaluation was conducted by a LIP within an hour of initiating restraints.

On 4/3/14 a review of the 12/2013 hospital policy and procedure titled "Restraint and Seclusion" indicated a qualified practitioner must perform and document a face-to-face assessment of the patient.

Based on interview and record review, the hospital failed to provide evidence Qualified Registered Nurses (QRN) performing the one hour face-to-face assessments of patients placed in restraints had the adequate training to perform mental status exams (MSE). The MSE training content was not specific on how to perform MSE assessments. Findings:

During an interview on 4/3/14 at 8:35 a.m., the director of nurses (DON) stated the hospital had three QRN trained to perform the one hour face-to-face evaluations of patients placed on restraints.

On 4/3/14 a review of the undated training material titled "Qualified Registered Nurse (QRN) One Hour Face to Face Evaluation of Seclusion and Restraints" indicated a mental status and behavioral evaluation must be completed for the patient. The training material indicated to assess the patient for certain factors including the patient's insight, appearance, affect, thought process, behavior, mood, speech, cognitive functioning, and thought content. The training document did not explain how to perform the above assessments. The training document was too general and lacked guidance on how to perform an MSE.

On 4/3/14 a review of the 12/2013 hospital policy and procedure titled "Restraint and Seclusion" indicated only qualified practitioners perform "face-to-face" assessments. Essential components to be assessed include a complete review of systems. A registered nurse "may evaluate the patient within one hour of the initiation of restraint...provided that they are trained."