HospitalInspections.org

Based on review of one (1) of four (4) personnel files (Staff #7) and staff interviews, it was determined that the facility failed to ensure that all staff caring for patients at risk for self-harm or harm to others, receive annual education and training.

Findings include:

1. During a tour of the Emergency Department (ED) on 3/8/21 at 11:20 AM, an interview was conducted with Staff #7. Staff #7 stated he/she cares for suicidal and homicidal patients in the ED by performing one-to-one (1:1) observation to ensure their safety.

a. A request was made to Staff #2 for Staff #7's education and training regarding the care of suicidal/homicidal patients, restraints, and performing 1:1 observation.

2. On 3/9/21 at 1:40 PM, Staff #19 stated, "We do not have education and training for [Staff #7] on caring for suicidal/homicidal patients, restraints, and 1:1 observation for 2019, 2020, or 2021."

3. Upon interview on 3/9/21 at 1:40 PM, Staff #20 confirmed staff are required to perform annual competencies on caring for suicidal/homicidal patients, restraints, and 1:1 observation.

Based on review of one (1) of four (4) medical records, staff interview, and review of the facility restraint policy, it was determined that the facility failed to ensure that a physician order is obtained upon initiation of restraints, in accordance with facility policy.

Findings include:

Reference: Facility policy titled, "Restraint and Seclusion: states, "... A. Use of Restraints for (Nonviolent/Nonself-destructive - Medical Support) Orders should: Be obtained prior to the use of restraint(s) whenever possible... Obtained to reinstate the restraint, if a patient is removed from restraint(s)."

1. Medical Record #4

a. On 3/9/21 at approximately 11:30 AM, review of the Restraint Monitoring Assessment, indicated that bilateral upper extremity soft limb restraints were applied to the patient on 3/9/21 at 8:00 AM. At 10:00 AM, a subsequent restraint assessment was documented.

i. Upon review of the Physician's Orders, there was no order found for the application of restraints.

b. Upon interview at 11:31 AM, Staff #31 stated that an order is typically obtained within 1 hour of the initiation of restraints.

i. At 11:34 AM, Staff #3 stated that for non-violent restraints, the physician must see the patient and write an order within 24 hours of application of the restraints.

2. The above findings were confirmed with Staff #1.

Based on review of two (2) of four (4) medical records, staff interview, and review of facility policy, it was determined that the facility failed to ensure that a physician order is obtained upon renewal of restraints, in accordance with facility policy.

Findings include:

Reference: Facility policy titled, "Restraint and Seclusion" states, "... A. Use of Restraints for (Nonviolent/Nonself-destructive - Medical Support) Orders should: ... Renewed if necessary, each day, not to exceed 24 hours following an examination by the Physician/LIP. If orders are not renewed within the timeframe restraints must be discontinued. Orders may be renewed according to the time limits for a maximum of 24 consecutive hours."

1. On 3/9/21, during review of Medical Records #3 and #6, the following was revealed:

a. Medical Record #3

i. On 2/21/21, mitts were applied to Patient #3's hands due to his/her interference with medical devices. A Physician's Order was in place.

ii. Review of the Restraint Monitoring Assessment record indicated, that from 2/21 until 2/29/21, mitts were used on the patient.

iii. Upon interview at 11:58 AM, Staff #33 stated that mitts are treated the same as a non-violent soft limb restraint. A physician's order is required to renew be renewed every 24 hours.

iv. Review of the Physician Orders indicated that on 2/27/21, there was no evidence of a physician's order to renew the use of mitts.

b. Medical Record #6

i. On 2/28/21, Patient #6 was placed in non-violent bilateral soft limb restraints on his/her upper extremities due to the patient interfering with medical devices.

ii. Review of the Physician Orders indicated that orders were written for "Restraint Initiation" on 2/28/21 and on 3/1/21.

iii. Review of Restraint Monitoring Assessments indicated that the patient was on soft limb restraints on 2/28/21, 3/1/21, and 3/2/21.

iv. There was no physician order to renew the restraints for 3/2/21.

2. The above findings were confirmed with Staff #1.