HospitalInspections.org

Based on review of records and interview, it was determined that the facility failed to protect and promote each patients rights when:

" Violent/self-destructive patients determined by hospital definition were placed in non-violent restraints which requires less monitoring of the patient. This action places the patient, other hospital patients and staff at risk for serious harm.
" Failure of the hospital to obtain physician orders for patients that were placed in restraints.
" Failure to appropriately complete restraint documentation sheets of patients placed in restraints suggest the patient may not have been monitored by staff appropriately putting the patient at risk for harm.
" Failure to ensure that patients placed in restraints for violent/self-destructive behaviors were reassessed and an order obtained to continue the restraint every 4 hours for an adult and every two hours for children 9-17 years of age.

Findings were

Based on facility policy review, medical record review and interview, the facility failed to ensure the use of restraints were implemented in accordance with safe and appropriate techniques as determined by hospital policy in accordance with State law.

Findings included:

Facility policy titled, "Restraint and Seclusion" stated in part, "Policy:

A. It is the policy of Northwest Texas Healthcare System to support each patient's right to be free from restraint or seclusion and therefore limit the use of these interventions to emergencies in which there is an imminent risk of a patient physically harming him/her or others ...

F. The use of restraint must be in accordance with the order of a physician or licensed independent practitioner (LIP) ...

J. Orders

1. Violent/Self Destructive:

a. Each order for restraint or seclusion for violent or self-destructive behavior may be only renewed in accordance with the following time limits for up to a total of 24 hours ... (2) 2 hours for children and adolescents 9-12 years of age ...

K. Ongoing Monitoring:

...2. Non-Violent/Non-Self Destructive:

a. Restraint not used for the management of violent behavior shall be subject to ongoing monitoring and assessment as specified in the patient's plan of care. Monitoring is expected to occur a minimum of every 2 hours.

...c. Documentation of Monitoring: Episodes of restraint shall be documented as indicated on currently approved assessments, monitoring and ordering forms and computer screens and may include skin integrity, hygiene, nutrition, elimination, circulation, vital signs, and reaction to restraints, Concurrent documentation of monitoring is not required, however, a statement that monitoring occurred, with variances in care noted (if any) must be annotated by the end of the nurse's shift."

Review of patient #1's medical record revealed nursing documentation of ongoing monitoring and assessment a minimum of every 2 hours was not found for the 7:00 am to 7:00 pm shift on 3/10/17 and 3/12/17. Documentation should be followed for violent restraints.

Review of patient #10's medical record revealed an order dated 2/27/17 at 7:10 pm stated in part, "Restraint Nonviolent." The following was not consistent with facility policy.

Nursing documentation on 2/27/17 at 4:00 pm stated in part, "(Violent Restraint Justification) Attempting to hurt self, Attempting to hurt others, Violence towards environment." Nursing documentation of ongoing assessment was not found.

Nurse #12 documented the following, in part:
" On 2/27/17 at 9:06 pm "Violent Restraint Criteria for Release"
" On 2/28/17 at 6:03 am "Restraint NV [nonviolent] Monitoring Statement"

Nurse #13 documented the following, in part:
" On 2/28/17 at 2:52 pm "Violent Restraint Criteria for Release"
" On 2/28/17 at 6:55 pm "Restraint NV Monitoring Statement"
" On 3/1/17 at 12:24 pm "Violent Restraint Criteria for Release"
" On 3/1/17 at 6:53 pm "Restraint NV Monitoring Statement"

The following shifts had no nursing documentation of restraints:
" 3/1/17: 7 pm - 7 am
" 3/5/17: 7 pm - 7 am
" 3/6/17: 7 am - 7 pm

The following shifts had no nursing documentation of ongoing monitoring and assessment:
" 2/27/17: 7 am - 7 pm
" 2/28/17: 7 pm - 7 am
" 3/2/17: 7 pm - 7 am
" 3/3/17: 7 pm - 7 am
" 3/4/17: Both Shifts

Nursing documentation for patient #10 was inconsistent with facility policy and among nursing staff.
The above was confirmed in an interview with the Director of Quality on the afternoon of 3/11/17.

Based on review of facility documents, review of medical records and interview, the facility failed to ensure the use of restraint was in accordance with the order of a physician.

Findings included:

Facility policy titled, "Restraint" stated in part, "The use of restraint must be in accordance with the order of a physician or licensed independent practitioner (LIP) ..."

Review of patient #1's medical record revealed patient was in restraints on 3/7/17, 3/8/17 and 3/9/17. There was no order for restraints until 3/9/17 at 10:00 pm.

The above was verified in an interview with the Chief Nursing Officer on the afternoon of 6/13/17

Based on review of facility policy, review of medical records and interview, the facility failed to ensure each restraint used for the management of violent or self-destructive behavior was in accordance with the 4 hour time limit for adults and 2 hours for children 9-17 years of age.

Findings were:

Facility policy entitled "Restraint and Seclusion" stated in part
"Orders
1. Violent/Self Destructive:
a. Each order for restraint or seclusion for violent or self-destructive behavior may be only be renewed in accordance with the following time limits for up to a total of 24 hours:
1) 4 hours for adults 18 years of age or older
2) 2 hours for children and adolescents 9-17 years of age; or
3) 1 hour for children under 9 years of age
4) 15 minutes for personal hold

b. After 24 hours, before writing a new order for use of restraint or seclusion, a physician or other licensed independent practitioner who is responsible for the care of the patient must see and assess the patient. The re-evaluation supporting the continued use of restraint or seclusion must be documented in the patient's record."

Patient # 1, 14 years old, was restrained for 7 days for aggressive behavior . Orders for restraint were not recieved every 2 hours according to facility policy.

Patient # 10 was restrained for 11 days for violent behavior. Orders for restraint were not received every 4 hours according to facility policy.

In an interview with the Director of Nurses on 6/13/17, the above findings were acknowledged.