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Based on the hospital's policy review, medical record review, staff interview, the hospital failed to ensure that a time limited order of no longer than four (4) hours was ordered for a patient with violent or self-destructive behavior in 1 of 3 sampled patients (Patient #13).

Findings include:

A review on 11/09/2011 of the hospital's policy "Restrictive Interventions" (reviewed/revised 07/2011) revealed "I. Policy...H. Violent/Self-destructive Restraint Orders...5. Each written order is limited to four (4) hours for adults."

A closed medical record review on 11/09/2011 for patient #13 revealed that the patient was a 70 year old female admitted to the hospital 09/19/2011 through 09/28/2011 on the hospital's telemetry unit. The review of the medical record revealed that the patient was restrained by the hospital's staff on 09/19/2011 through 09/26/2011 for a total of seven (7) days. Review of the patient's medical record revealed that the patient's restraint orders for a "Vest and siderail protectors/siderail gap" were documented on the hospital's form "Non-Violent Restrictive Intervention Order." The documentation review revealed the MD (Physician) Assessment on the forms as the following:

~Physician Restraint Order 09/19/2011 at 1045 "Patient pulling at lines, striking staff multiple times."
~Physician Restraint Order 09/20/2011 at 1000 "Combative and may harm self and others."
~Physician Restraint Order 09/21/2011 at 1000 "Ms__ (patient name) will hurt herself and others if we don't use restraints"
~Physician Restraint Order 09/24/2011 at 1000 "Still agitated and confused. May hurt self and others."
~Physician Restraint Order 09/25/2011 at 1130 "Still needs it, confused gets agitated and may hurt self or others."
~Physician Restraint Order 09/26/2011 at 1000 "Patient still confused and may hurt herself and others."

The review of the patient's written orders for restraints on the dates of 09/19/2011, 09/20/2011, 09/21/2011, 09/24/2011, 09/25/2011, and 09/26/2011 were all for Non-Violent Restrictive Intervention Orders and without any four (4) hour time limits. The review of the patient's medical record further revealed that the hospital's staff documented the patient as a non-violent, non-self destructive patient as the justification for the patient's restraints.

An interview on 11/09/2011 at 1030 with the hospital's administrative staff in restraint utilization revealed that the patient was ordered for "Non-Violent Restraints" even though her physician assessment indicated that the patient was "combative and a harm to herself and others." The interview revealed that the patient, based on the documentation, should have had a time limited written order for restraints of up to four (4) hours according to hospital policy.

An interview on 11/09/2011 at 1050 with the hospital's administrative nursing staff on the telemetry unit revealed "The patient was trying to bite and hit at the staff. She was a harm to others and combative." The interview revealed that the nursing staff did agree with the physician assessments on the restraint order forms.

Based on hospital policy review, medical record review, and staff interview, the hospital failed to ensure ongoing monitoring of a patient's condition in 2 of 3 sampled patients restrained for violent or self-destructive behaviors in accordance with the hospital's policies and procedures (Patient #13, #3).

Findings include:

A review on 11/09/2011 of the hospital's policy "Restrictive Interventions" (reviewed/revised 07/2011) revealed "VII..Intervention..G. Assessment/Monitoring/Patient care: violent self destructive restrictive intervention utilization...1. Assess and document at initiation and every 15 minutes: a. Respiratory quality and/or rate..b. Restrictive interventions device in use..c. Readiness for discontinuation of restraint/seclusion...d. Safety and circulation adequate...e. Less restrictive methods or alternatives...f. Meets criteria to continue restrictive interventions."

1. A closed medical record review on 11/09/2011 for patient #13 revealed that the patient was a 70 year old female admitted to the hospital 09/19/2011 through 09/28/2011 on the hospital's telemetry unit. The review of the medical record revealed that the patient was restrained by the hospital's staff on 09/19/2011 through 09/26/2011 for a total of seven (7) days. Review of the patient's medical record revealed that the patient's restraint orders for a "Vest and siderail protectors/siderail gap" were documented on the hospital's form "Non-Violent Restrictive Intervention Order." The documentation review revealed the MD (Physician) Assessment on the forms as the following:

~Physician Restraint Order 09/19/2011 at 1045 "Patient pulling at lines, striking staff multiple times."
~Physician Restraint Order 09/20/2011 at 1000 "Combative and may harm self and others."
~Physician Restraint Order 09/21/2011 at 1000 "Ms__ (patient name) will hurt herself and others if we don't use restraints"
~Physician Restraint Order 09/24/2011 at 1000 "Still agitated and confused. May hurt self and others."
~Physician Restraint Order 09/25/2011 at 1130 "Still needs it, confused gets agitated and may hurt self or others."
~Physician Restraint Order 09/26/2011 at 1000 "Patient still confused and may hurt herself and others."

The review of the patient's monitoring on the dates of 09/19/2011, 09/20/2011, 09/21/2011, 09/24/2011, 09/25/2011, and 09/26/2011 all revealed that the patient was only monitored by the hospital's staff and physicians every hour and not every 15 minutes as required in the hospital's policy and procedure for "Violent self destructive behavior." The review of the patient's medical record further revealed that the hospital's staff documented the patient as a non-violent, non-self destructive patient as the justification for the patient's restraints.

An interview on 11/09/2011 at 1030 with the hospital's administrative staff in restraint utilization revealed that the patient was ordered for "Non-Violent Restraints" even though her physician assessment indicated that the patient was "combative and a harm to herself and others." The interview revealed that the patient based on the documentation should have been restrained with every 15 minute monitoring according to hospital policy.

An interview on 11/09/2011 at 1050 with the hospital's administrative nursing staff on the telemetry unit revealed "The patient was trying to bite and hit at the staff. She was a harm to others and combative." The interview revealed that the nursing staff did agree with the physician assessments on the restraint order forms.



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2. Closed record review on 11/09/2011 for Patient #3 revealed a 10 year old female who presented to the facility's Emergency Department (ED) by law enforcement on 10/12/2011 under Involuntary Commitment (IVC) papers for medical clearance and psychiatric hospital placement. Review revealed the patient was placed in 4-point restraints (both arms and both legs restrained at the wrists and ankles) on 10/15/2011 from 1350 until 1435 for "Pt (patient) is banging head on walls, banging arms against door and walls." Review of documentation revealed hand-written documentation on a form "Nurses' Notes (Downtime)" of blood pressure, oxygen saturation, respiratory rate and pulse rate at 1350, 1405, 1415, 1430 and 1435 with comments at 1415 "pt. crying, pt states I want my dad..." at 1430 "Pt calm/cooperative" and at 1435 "pt. coloring (symbol for after) attempt to use BSC (bedside commode). pt calm/cooperative so restraints removed per nurse." Review revealed the name of a Patient Care Technician (PCT) at the top of the handwritten form. Further review of electronic documentation revealed information entered by a Registered Nurse (RN) regarding the restraints initiated on 10/15/2011 at 1350. Review revealed the restraints were "Violent/Self-Destructive" for "Dangerous to self, Dangerous to Others." Review revealed the information was entered by the RN on different dates and varying times to include the dates 10/15/2011, 10/16/2011 and 10/29/2011. Review revealed the electronic documentation included monitoring of heart rate, respiratory rate, blood pressure, oxygen saturation at dated 10/15/2011 at 1350, and dated 10/15/2011 at 1405, 1415 and 1430 documentation to include assessment of respiratory rate, restrictive device in use, readiness for discontinuation, safety and circulation, alternatives to restraint and criteria to continue restraints. Further review revealed documentation at 1415 and 1430 the restraint monitoring was provided by a different PCT than the PCT documenting on the handwritten "Nurses' Notes" downtime form.

Interview on 11/10/2011 at 1110 with the PCT who documented the handwritten restraint monitoring on the downtime form "Nurses' Notes" revealed the PCT was not present during the restraint application. Interview revealed the PCT noted as monitoring the patient in the electronic documentation was present when the restraints were initiated and she took over at approximately 1415. Interview revealed the PCT only documented the patient's blood pressure, oxygen saturation, respiratory rate and pulse rate at 1350, 1405, 1415, 1430 and 1435 with the comments. Interview revealed the PCT did not document monitoring of restrictive device in use, readiness for discontinuation, safety and circulation, alternatives to restraint and criteria to continue restraints. Interview revealed the electronic documentation was entered by the primary RN for Patient #3. Interview revealed "I told her the other things" which were not documented on the handwritten flowsheet by the PCT. Interview revealed "Its hard to document in the computer while your monitoring the patient". Interview revealed "Its easier for the nurse to put the information in for me." Interview revealed the nurse who entered the electronic documentation was not present during the monitoring of the patient.

Interview on 11/10/2011 at 1015 with emergency department administrative staff revealed the nurse who entered the electronic restraint documentation was not available for interview. Interview revealed the monitoring of restrictive device in use, readiness for discontinuation, safety and circulation, alternatives to restraint and criteria to continue restraints was documented by a different staff member (the patient's primary RN) than the PCT who was performing the monitoring. Interview revealed there was no documented evidence the PCT observing Patient #3 while in 4-point restraint documented or monitored the restrictive device in use, readiness for discontinuation, safety and circulation, alternatives to restraint and criteria to continue restraints. Interview revealed "We need some work in this area (restraint documentation)."

Based on review of facility policies and procedures, medical records and staff interviews staff failed to ensure vital signs were monitored per facility policy for two of 10 emergency department records reviewed (#3, #2).

Findings include:

Review on 11/09/2011 of facility policy "Assessment - Reassessment of the Emergency Department Patient" dated 07/2011 revealed "C.1. Psych(iatric) patients' vital signs reassessed every 8 hours when medically cleared."

1. Closed record review on 11/09/2011 for Patient #3 revealed a 10 year old female who presented to the facility's Emergency Department (ED) by law enforcement on 10/12/2011 under Involuntary Commitment (IVC) papers for medical clearance and psychiatric hospital placement. Review revealed the patient was medically cleared for psychiatric hospital admission on 10/12/2011. Review revealed the patient was in the facility's ED as an IVC until transfer to a psychiatric facility by law enforcement on 10/26/2011. Review revealed the patient's vital signs were monitored on 10/13/2011 at 0800 and again on 10/13/2011 at 1815 (10 hours and 15 minutes). Review revealed the patient's vital signs were monitored on 10/14/2011 at 0800 and again on 10/14/2011 at 1820 (10 hours and 20 minutes). Review revealed the patient's vital signs were monitored on 10/14/2011 at 1820 and again on 10/15/2011 at 1350 (18 hours and 30 minutes). Review revealed the patient's vital signs were monitored on 10/15/2011 at 1415 and again on 10/16/2011 at 0600 (15 hours and 45 minutes). Review revealed the patient's vital signs were monitored on 10/16/2011 at 2130 and again on 10/17/2011 at 0700 (9 hours and 30 minutes). Review revealed the patient's vital signs were monitored on 10/17/2011 at 1445 and again on 10/18/2011 at 0700 (16 hours and 15 minutes). Review revealed the patient's vital signs were monitored on 10/18/2011 at 1300 and again on 10/19/2011 at 0230 (13 hours and 30 minutes). Review revealed the patient's vital signs were monitored on 10/21/2011 at 1419 and again on 10/21/2011 at 2345 (9 hours and 26 minutes). Review revealed the patient's vital signs were monitored on 10/23/2011 at 1521 and again on 10/24/2011 at 0620 (14 hours and 59 minutes). Review revealed the patient's vital signs were monitored on 10/24/2011 at 0620 and again on 10/24/2011 at 1600 (9 hours and 40 minutes). Review revealed the patient's vital signs were monitored on 10/24/2011 at 2035 and again on 10/25/2011 at 0800 (11 hours and 25 minutes). Review revealed the patient's vital signs were monitored on 10/26/2011 at 0000 and again on 10/26/2011 at 0930 (9 hours and 30 minutes).

2. Closed record review on 11/09/2011 for Patient #2 revealed a 10 year old female, and twin to Patient #3, who presented to the facility's Emergency Department (ED) by law enforcement on 10/12/2011 under Involuntary Commitment (IVC) papers for medical clearance and psychiatric hospital placement. Review revealed the patient was medically cleared for psychiatric hospital admission on 10/12/2011. Review revealed the patient was in the facility's ED until the IVC was discontinued by the ED physician on 10/28/2011 and the patient was discharged to the mother and grandmother for transport to a psychiatric facility. Review revealed the patient's vital signs were monitored on 10/12/2011 at 2300 and again on 10/13/2011 at 1430 (15 hours and 30 minutes). Review revealed the patient's vital signs were monitored on 10/14/2011 at 0730 and again on 10/14/2011 at 1819 (10 hours and 49 minutes). Review revealed the patient's vital signs were monitored on 10/16/2011 at 0645 and again on 10/17/2011 at 0145 (19 hours). Review revealed the patient's vital signs were monitored on 10/18/2011 at 1245 and again on 10/19/2011 at 0230 (18 hours and 45 minutes). Review revealed the patient's vital signs were monitored on 10/20/2011 at 0030 and again on 10/20/2011 at 1540 (15 hours and 10 minutes). Review revealed the patient's vital signs were monitored on 10/20/2011 at 2245 and again on 10/21/2011 at 1100 (12 hours and 15 minutes). Review revealed the patient's vital signs were monitored on 10/23/2011 at 0700 and again on 10/24/2011 at 0650 (23 hours and 50 minutes). Review revealed the patient's vital signs were monitored on 10/24/2011 at 0650 and again on 10/24/2011 at 1600 (9 hours and 10 minutes). Review revealed the patient's vital signs were monitored on 10/26/2011 at 0000 and again on 10/26/2011 at 1400 (14 hours). Review revealed the patient's vital signs were monitored on 10/26/2011 at 1400 and again on 10/27/2011 at 0100 (11 hours).

Interview on 11/09/2011 at 1505 with ED administrative staff revealed the vital signs for Patients #3 and #2 should be monitored and documented every 8 hours. Interview revealed "We recognized opportunities for improvement." Interview revealed there were days the vital signs for Patients #3 and #2 were not taken every eight hours as per facility policy for psychiatric patients. Interview failed to reveal any further documentation the vital signs for Patients #3 and #2 were monitored every eight hours. Interview revealed staff failed to follow facility policy by failing to monitor psychiatric patient's vital signs every eight hours.

Based on review of facility policies and procedures, medical records and staff interviews staff failed to document an indication for as need (PRN) medications and failed to reassess the patient following administration of PRN medications for control of behavior for two of 10 emergency department records reviewed (#3, #2).

Findings included:

Review on 11/09/2011 of facility policy " Documentation Guidelines" dated 01/2011 revealed "V. Planning...Response to medications/treatments will be recorded in the patient record..."

Review on 11/09/2011 of facility policy "Medication Administration" dated 04/2011 revealed "C. Electronic MAR...5. For PRN medications, document...reason given with a patient response, within one hour..."

1. Closed record review on 11/09/2011 for Patient #3 revealed a 10 year old female who presented to the facility's Emergency Department (ED) by law enforcement on 10/12/2011 under Involuntary Commitment (IVC) papers for medical clearance and psychiatric hospital placement. Review revealed on 10/13/2011 at 0845 the patient was administered Ativan (antianxiety medication) 2mg (milligrams) intramuscular (IM). Review failed to reveal any reassessment of patient response was performed within one hour after the medication administration. Review revealed on 10/13/2011 at 1106 the patient was administered Haldol (antipsychotic medication) 3mg IM and at 1111 Versed (sedative medication) 1mg IM with no indication or reason for administration of the medications. Review further failed to reveal any reassessment of response was performed within one hour after the Haldol and Ativan were administered. Review revealed on 10/14/2011 at 0857 the patient was administered Haldol 2mg IM and Ativan 1mg IM. Review failed to reveal any reassessment of patient response was performed within one hour after the medications were administered. Review revealed on 10/15/2011 at 1030 the patient was administered Haldol 2mg IM and Ativan 1mg IM. Review failed to reveal any indication for administration or reassessment of patient response was performed within one hour after the medications were administered. Review revealed on 10/15/2011 at 1225 the patient was administered Haldol 2mg IM and Ativan 1mg IM. Review failed to reveal any indication for administration or reassessment of patient response was performed within one hour after the medications were administered. Review revealed on 10/15/2011 at 1600 the patient was administered Haldol 3mg IM and Ativan 1mg IM. Review failed to reveal any reassessment of patient response was performed within one hour after the medications were administered. Review revealed on 10/17/2011 at 0730 and at 0915 the patient was administered Haldol 3mg IM and Ativan 2mg IM. Review failed to reveal any reassessment of patient response was performed within one hour after the medications were administered. Review revealed on 10/18/2011 at 0745 the patient was administered Haldol 3mg IM and Ativan 1mg IM. Review failed to reveal any indication for the reason the medications were administered. Review revealed on 10/18/2011 at 1328 the patient was administered Haldol 3mg IM and Ativan 1mg IM. Review failed to reveal any reassessment of patient response was performed within one hour after the medications were administered. Review revealed on 10/19/2011 at 1205 the patient was administered Ativan 1mg IM and at 1206 Haldol 3mg IM. Review failed to reveal any indication for administration or reassessment of patient response was performed within one hour after the medications were administered. Review revealed on 10/20/2011 at 2111 the patient was administered Haldol 3mg IM and Ativan 1mg IM. Review failed to reveal any reassessment of patient response was performed within one hour after the medications were administered. Review revealed on 10/22/2011 at 1320 the patient was administered Ativan 1mg IM. Review failed to reveal any reassessment of patient response was performed within one hour after the medication was administered. Review revealed on 10/22/2011 at 1320 the patient was administered Ativan 1mg IM. Review failed to reveal any indication for administration or reassessment of patient response was performed within one hour after the medication was administered. Review revealed on 10/23/2011 at 0815 the patient was administered Ativan 1mg IM. Review failed to reveal any indication for administration or reassessment of patient response was performed within one hour after the medication was administered. Review revealed on 10/22/2011 at 1418 the patient was administered Ativan 1mg IM. Review failed to reveal any indication for administration of the medication.

2. Closed record review on 11/09/2011 for Patient #2 revealed a 10 year old female, and twin to Patient #3, who presented to the facility's Emergency Department (ED) by law enforcement on 10/12/2011 under Involuntary Commitment (IVC) papers for medical clearance and psychiatric hospital placement. Review revealed on 10/18/2011 at 1125 the patient was administered Ativan 1mg IM. Review failed to reveal any reassessment of patient response was performed within one hour after the medication was administered. Review revealed on 10/18/2011 at 1137 the patient was administered Haldol 1mg IM. Review failed to reveal any indication for administration or reassessment of patient response was performed within one hour after the medication was administered. Review revealed on 10/20/2011 at 2045 the patient was administered Haldol 2mg IM and Ativan 1mg IM. Review failed to reveal any indication reassessment of patient response was performed within one hour after the medications were administered. Review revealed on 10/26/2011 at 1415 the patient was administered Ativan 1mg IM. Review failed to reveal any reassessment of patient response was performed within one hour after the medication was administered.

Interview on 11/10/2011 at 0930 with ED administrative staff revealed PRN medications such as Haldol, Versed and Ativan should have a documented reason why the medication was administered (indication) and a reassessment of response to the medication documented within one hour after the medication was administered. Interview revealed "We recognized opportunities for improvement." Interview revealed there were "several" incidences of medications without indications for administration and medications without reassessment of response to the medications. Interview failed to reveal any further documentation the reviewed medications administered for Patients #3 and #2 had indications for administration and reassessment of response. Interview revealed staff failed to follow facility policy by failing to document an indication for PRN medication administration and reassessment of response to a PRN medication.

NC000766295