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Based on hospital policy and procedure reviews, medical record reviews, and staff interviews the hospital's nursing staff failed to obtain a physician's order for restraint for 1 of 1 patients restrained for the management of violent or self-destructive behaviors (#9).

The findings include:

Review of current hospital policy "Restraint Application And Use Policy," approved 11/21/2014, revealed "...RESTRAINT ORDERS AND RENEWAL ORDERS 1. Restraint or seclusion must be ordered by a provider recognized by the state of North Carolina and credentialed by (Hospital name). The type of restraint ordered will depend on patient condition and observed patient behaviors..."

Review of current hospital policy "Restraint Application And Use Procedure," approved 11/20/2014, revealed "...PROCEDURE: 1. PATIENT ASSESSMENT ...1.2 Once it has been deemed that restraints are needed and alternatives to restraints failed, obtain order from provider (Required Action Steps). ..."

Closed medical record review on 01/08/2015 for Patient #9 revealed a 50 year old male presented to the hospital's emergency department on 08/06/2014 at 1642 with chief complaints of Depression, Suicidal Ideation, and Anxiety. Review revealed the patient was evaluated and subsequently voluntarily admitted to the hospital's inpatient Behavioral Health Unit (BHU). Review revealed on 08/09/2014 at 2012 the patient was transferred to the hospital's Intensive Care Unit (ICU) for chest pain and low blood pressure. Review of ICU nursing documentation on 08/10/2014 at 0223 revealed "Called to ICU, room 483- Patient acting out, yelling and cursing. Screams 'I'm suing the f**king hell out of this godd****d hospital!' Dr. (Physician A) in to speak with patient. Patient continues to yell and curse, demanding transfer to (Hospital B). ...Patient refuses ordered Trazodone, continue to curse. Patient asked to lower his voice, and door to room shut (glass door; full visibility maintained). Patient continues to yell and curse. ...Patient grew angrier. Asked to return to bed by nursing supervisor and security officers. Patient lunged from bed and grabbed security officer's leg. Patient restrained for staff safety; released as soon as he calmed and became noncombative. Patient jerked away and cursed, made threat toward staff. ...Restraints available, but patient settling somewhat; we declined their use as unnecessary at this time." Record review failed to reveal any available documentation of a physician's order for the use of the physical restraint (manual hold) on Patient #9 for the management of violent or self-destructive behaviors on 08/10/2014 at 0223.

Interview on 01/09/2015 at 1035 with Director #1 and Director #2 revealed "it appeared the restraint was a short hold." Interview revealed "it happened quickly and the staff possibly did not consider the need for restraint orders and documentation." Interview revealed when a patient is physically restrained the expectation is for the staff to follow the hospital's restraint policies. Interview revealed the staff should have obtained a time-limited physician's order for restraint. Interview revealed the staff did not follow the hospital's restraint application and use policy and procedures.

Based on hospital policy and procedure reviews, medical record reviews, and staff interviews, the hospital's nursing staff failed to ensure a physician's restraint order was time-limited for no longer than four (4) hours for 1 of 1 adult patients age 18 years or older who was restrained for the management of violent or self-destructive behaviors (#9).

The findings include:

Review of current hospital policy "Restraint Application And Use Policy," approved 11/21/2014, revealed "...RESTRAINT ORDERS AND RENEWAL ORDERS 1. Restraint or seclusion must be ordered by a provider recognized by the state of North Carolina and credentialed by (Hospital name). The type of restraint ordered will depend on patient condition and observed patient behaviors. ...6. Restraint or seclusion renewal orders for adult Violent (behavioral) restraint are obtained every four (4) hours. ...9. Behavioral (Violent) Restraint and Seclusion orders must be renewed at the following frequencies: *Adults: Every four (4) hours ..."

Review of current hospital policy "Restraint Application And Use Procedure," approved 11/20/2014, revealed "...PROCEDURE: 1. PATIENT ASSESSMENT ...1.2 Once it has been deemed that restraints are needed and alternatives to restraints failed, obtain order from provider (Required Action Steps). ..."

Closed medical record review on 01/08/2015 for Patient #9 revealed a 50 year old male presented to the hospital's emergency department on 08/06/2014 at 1642 with chief complaints of Depression, Suicidal Ideation, and Anxiety. Review revealed the patient was evaluated and subsequently voluntarily admitted to the hospital's inpatient Behavioral Health Unit (BHU). Review revealed on 08/09/2014 at 2012 the patient was transferred to the hospital's Intensive Care Unit (ICU) for chest pain and low blood pressure. Review of ICU nursing documentation on 08/10/2014 at 0223 revealed "Called to ICU, room 483- Patient acting out, yelling and cursing. Screams 'I'm suing the f**king hell out of this godd****d hospital!' Dr. (Physician A) in to speak with patient. Patient continues to yell and curse, demanding transfer to (Hospital B). ...Patient refuses ordered Trazodone, continue to curse. Patient asked to lower his voice, and door to room shut (glass door; full visibility maintained). Patient continues to yell and curse. ...Patient grew angrier. Asked to return to bed by nursing supervisor and security officers. Patient lunged from bed and grabbed security officer's leg. Patient restrained for staff safety; released as soon as he calmed and became noncombative. Patient jerked away and cursed, made threat toward staff. ...Restraints available, but patient settling somewhat; we declined their use as unnecessary at this time." Record review failed to reveal any available documentation of a physician's order for the use of the physical restraint (manual hold) on Patient #9 for the management of violent or self-destructive behaviors on 08/10/2014 at 0223.

Interview on 01/09/2015 at 1035 with Director #1 and Director #2 revealed "it appeared the restraint was a short hold." Interview revealed "it happened quickly and the staff possibly did not consider the need for restraint orders and documentation." Interview revealed when a patient is physically restrained the expectation is for the staff to follow the hospital's restraint policies. Interview revealed the staff should have obtained a time-limited physician's order for restraint. Interview revealed the staff did not follow the hospital's restraint application and use policy and procedures.

Based on hospital policy and procedure reviews, medical record reviews, and staff interviews the hospital's nursing staff failed to ensure the physician or other licensed independent practitioner (LIP) or trained RN conducting the face-to-face evaluation within 1 hour after the initiation of restraint evaluated the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; and the need to continue or terminate the restraint for 1 of 1 patients (#9) restrained for the management of violent or self-destructive behaviors.

The findings include:

Review of current hospital policy "Restraint Application And Use Policy," approved 11/21/2014, revealed "...RESTRAINT ORDERS AND RENEWAL ORDERS ...7. A provider must perform a face-to-face assessment of the patient within one (1) hour of application of Violent (behavioral) restraints... 8. The in-person evaluation, conducted within one hour of the initiation of restraint or seclusion for the management of violent or self-destructive behavior that jeopardizes the physical safety of the patient, staff or others includes evaluation of the patient's immediate situation, reaction to interventions(s), and medical/behavioral condition. ..."

Review of current hospital policy "Restraint Application And Use Procedure," approved 11/20/2014, revealed "...PROCEDURE: ...2. APPLICATION OF RESTRAINT ...Providers must perform a face-to-face assessment of the patient after the application of restraints. The provider has time limits set for assessment based on the type of restraint used. ...*Behavioral (Violent) 1 hour... (Required Action Steps)..."

Closed medical record review on 01/08/2015 for Patient #9 revealed a 50 year old male presented to the hospital's emergency department on 08/06/2014 at 1642 with chief complaints of Depression, Suicidal Ideation, and Anxiety. Review revealed the patient was evaluated and subsequently voluntarily admitted to the hospital's inpatient Behavioral Health Unit (BHU). Review revealed on 08/09/2014 at 2012 the patient was transferred to the hospital's Intensive Care Unit (ICU) for chest pain and low blood pressure. Review of ICU nursing documentation on 08/10/2014 at 0223 revealed "Called to ICU, room 483- Patient acting out, yelling and cursing. Screams 'I'm suing the f**king hell out of this godd****d hospital!' Dr. (Physician A) in to speak with patient. Patient continues to yell and curse, demanding transfer to (Hospital B). ...Patient refuses ordered Trazodone, continue to curse. Patient asked to lower his voice, and door to room shut (glass door; full visibility maintained). Patient continues to yell and curse. ...Patient grew angrier. Asked to return to bed by nursing supervisor and security officers. Patient lunged from bed and grabbed security officer's leg. Patient restrained for staff safety; released as soon as he calmed and became noncombative. Patient jerked away and cursed, made threat toward staff. ...Restraints available, but patient settling somewhat; we declined their use as unnecessary at this time."
Review of a physician's progress note dated 08/10/2014 at 0230 by Physician A revealed "Asked to see pt (patient) for ongoing chest pain. Pt was sleeping peacefully per nursing and then woke up complaining of severe chest pain which he rates 10/10. Initial trop (troponin) negative. Initial ekg (electrocardiogram) similar to prior and repeat ekg unchanged. Ordering stat trop. BP's (blood pressure) have been lowish; pt received 25 mg (milligrams) of metoprolol (for blood pressure). Pt continues to be abusive verbally to staff and attempted to forcefully leave room; security here. Pt feels his CP is not due to anxiety but that it is cardiac. Reassured him that so far there is no evidence of cardiac ischemia and that we are continuing to evaluate him. IVC (involuntary commitment) papers are in progress." Record review failed to reveal any available documentation of a physician's face-to-face evaluation within 1 hour after the initiation of restraint on 08/10/2014 at 0223 that evaluated all of the following required elements: the patient's immediate situation; the patient's reaction to the intervention; the patient's medical and behavioral condition; and the need to continue or terminate the restraint.

Interview on 01/09/2015 at 1035 with Director #1 and Director #2 revealed "it appeared the restraint was a short hold." Interview revealed "it happened quickly and the staff possibly did not consider the need for restraint orders and documentation." Interview revealed when a patient is physically restrained the expectation is for the staff to follow the hospital's restraint policies. Interview revealed the staff did not follow the hospital's restraint application and use policy and procedures.

Based on hospital policy reviews, personnel file (PF) reviews, and staff interviews the hospital failed to develop its' restraint policy and procedures to identify ongoing training intervals for staff to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion, on a periodic basis for 2 of 2 restraint policies and procedures reviewed.

The findings include:

Review of current hospital policy "Restraint Application And Use Policy," approved 11/21/2014, revealed "POLICY STATEMENT: It is policy and philosophy of (Hospital name) to: ...8. Provide staff with orientation, training and continued education on the use of restraints. ...FACILITY RESPONSIBILITIES 1. (Hospital name) will provide training to all patient care providers and staff regarding the use of restraint including: restraint safety, patient evaluation and assessment as well as alternatives to restraint. Completion of restraint training will be documented. ..." Review of the policy failed to reveal any available documentation of defined timeframes identifying the ongoing training intervals for staff to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion, on a periodic basis per regulatory requirement.

Review of current hospital policy "Restraint Application And Use Procedure," approved 11/20/2014, revealed "...PROCEDURE: ...2. APPLICATION OF RESTRAINT NOTE: Restraints are to be applied only by qualified staff that have completed restraint competency and training by (Hospital Name). ...The following trained staff can initially apply restraints under the direction of a trained registered nurse (RN): *Security Officers..." Review of the policy failed to reveal any available documentation of defined timeframes identifying the ongoing training intervals for staff to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion, on a periodic basis per regulatory requirement.

Review of Security Officer (SO) PF #1 on 01/09/2015, revealed documentation of last restraint training on 04/11/2013 (1 year and 273 days ago). Review of a "Security Officer" job description signed on 09/30/2013 by the employee revealed under "Qualifications" and "Other" no requirement for completion of CPI (Crisis Prevention Institute - Non-violent crisis intervention), CPR (cardiopulmonary resuscitation), or Restraint/Seclusion training.

Review of Security Officer (SO) PF #2 on 01/09/2015, revealed documentation of last restraint training on 04/12/2013 (1 year and 272 days ago). Review of a "Security Officer" job description signed on 10/21/2013 by the employee revealed under "Qualifications" and "Other" no requirement for completion of CPI, CPR, or Restraint/Seclusion training.

Interview on 01/09/2015 at 1035 with Director #3 revealed Security Officers can assist with holding the patient's arm or leg for the nursing staff to apply the mechanical restraint. Interview revealed the Security Officers can perform physical escorts. Interview revealed all newly hired Security Officers complete initial CPI training. Interview revealed the Security Officers receive annual CPI review thereafter. Interview revealed Security Officers are CPR certified. Interview revealed the Director #3 did not know if it was written in policy that restraint education was required for Security Officers, however they reviewed restraint education annually. Interview revealed "the clinical education RN teaches restraints." Interview revealed Security Officers are not required to have first aid training or be certified in first aid. Interview revealed the Security Officer job description in SO PF #1 and SO PF #2 did not list CPI, CPR, and restraint training as a job requirement. Interview revealed the last documented restraint training in SO PF #1 and SO PF #2 was April of 2013 (greater than 1 year ago).

Interview on 01/09/2015 at 1104 with Staff Education Coordinator #1 revealed restraint training is provided to applicable staff upon hire during general hospital orientation. Interview revealed nursing staff receive didactic and hands on demonstration training for restraints in their clinical orientation and annually thereafter. Interview revealed seclusion is not covered during general orientation. Seclusion is covered in departmental specific training for staff only on the Behavioral Health Unit. Interview revealed Security Officers complete CPI training. Interview revealed Security Officers assist with restraint application, but do not apply the mechanical restraints. Interview revealed it is not mandatory for the Security Officers to complete annual restraint training. Interview revealed the hospital's current Restraint Application and Use Policy did not identify or define specific time frames for ongoing training intervals for staff to demonstrate competency in the application of restraints, implementation of seclusion, monitoring, assessment, and providing care for a patient in restraint or seclusion, on a periodic basis.

Based on hospital policy reviews, personnel file reviews, and staff interviews the hospital failed to ensure security officers assisting with application of restraints were trained in first aid techniques for 2 of 2 Security Officer (SO) personnel files (PF) reviewed. (PF #1, PF #2).

The findings include:

Review of current hospital policy "Restraint Application And Use Procedure," approved 11/20/2014, revealed "...PROCEDURE: ...2. APPLICATION OF RESTRAINT NOTE: Restraints are to be applied only by qualified staff that have completed restraint competency and training by (Hospital Name). ...The following trained staff can initially apply restraints under the direction of a trained registered nurse (RN): *Security Officers..."

Review of Security Officer PF #1 on 01/09/2015, revealed no available documentation of education and training in the use of first aid techniques.

Review of Security Officer PF #2 on 01/09/2015, revealed no available documentation of education and training in the use of first aid techniques.

Interview on 01/09/2015 at 1035 with Director #3 revealed Security Officers can assist with holding the patient's arm or leg for the nursing staff to apply the mechanical restraint. Interview revealed the Security Officers can perform physical escorts. Interview revealed Security Officers are not required to have first aid training or be certified in first aid. Interview revealed no documentation of education and training in first aid techniques in SO PF #1 and SO PF #2. Interview revealed the Director was unaware of the regulatory requirement for all staff who apply restraint or seclusion, monitor, access or provide care for a patient in restraint or seclusion to receive education and training in the use of first aid techniques.