HospitalInspections.org

Based of review and interview, the facility failed to;

1) ensure the Quality Assessment/Performance Improvement Department had trained staff and processes in place to ensure restraints [physical holds, mechanical restraints, and medications administered when a patient was a danger to self or others (chemical restraint/behavioral emergency medication administration)] were being used safely, appropriately, effectively, and only when necessary. The facility failed to follow its own policy for reducing the use of restraints through Performance Improvement.

Refer to Tag A0154


2) recognize that medications administered to restrain a patient behavior, resulting in restricting the patient's freedom of movement, was a Chemical Restraint/Emergency Behavioral Medication (EBM) administration and was prohibited to be written as a PRN (as needed) order in 1 of 1 (#1) patient charts reviewed.

The facility failed to ensure patient safety when administering sedative and psychotropic medications to control immediate behavioral emergencies. The facility failed to recognize emergency behavioral medications were chemical restraints and not therapeutic treatment in 1 of 1 (#1) patient charts reviewed.

The facility also failed to ensure staff conducted comprehensive patient assessments with escalation of behavior to determine patient needs and interventions prior to the administration of chemical restraints/emergency behavioral medication, and continuous monitoring after administering a chemical restraint/emergency behavioral medication for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 1 of 1 (#1) patient charts reviewed.

The facility failed to ensure a face to face evaluation was conducted following the administration of a chemical restraint/emergency behavioral medication to 1 of 1 (#1) patient charts reviewed. The face to face evaluation should be conducted within 1 hour of the restraint to determine the patient's immediate situation, patient's response to the restraint, and patient's medical and behavioral condition.

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.

Refer to Tag A0160


3) ensure medical staff documented the rationale for using multiple types of restraints as being the least restrictive measure to protect the patient and others from harm in 2 (Patient #4 and Patient #7) of 2 patients reviewed. The facility failed to ensure that medical and nursing staff followed the facility policy and procedures put in place to ensure the least restrictive measures were used and documented with descriptions of behaviors.

Refer to Tag A0166


4) ensure that restraints were only initiated and continued with complete physician orders for 3 (Patient #1, #4, and Patient #7) of 3 patients reviewed. Nursing staff initiated and continued restraints without obtaining or verifying a valid physician order.

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.

Refer to Tag A0168

Based on review of records and interview, the facility failed to ensure the Quality Assessment/Performance Improvement Department had trained staff and processes in place to ensure restraints [physical holds, mechanical restraints, and medications administered when a patient was a danger to self or others (chemical restraint/behavioral emergency medication administration)] were being used safely, appropriately, effectively, and only when necessary. The facility failed to follow its own policy for reducing the use of restraints through Performance Improvement.

Findings:

At the start of the survey, surveyors requested the restraint log for the previous 30 days.

Upon review of the restraint log, the only information on the restraint log was the Date, Account, Last Name, First Name, Middle Name, and Hospital.

Interview was conducted with Staff #3. Staff #3 was asked how she could tell the difference between behavioral/violent and medical/non-violent restraints based on the restraint log. Staff #3 explained that she could not. Staff #3 explained that she made a random selection of restraints each month off of the list of names and audited those. When asked how she could tell if the restraint used was a physical hold, mechanical restraint, or a medication given during a behavioral emergency (chemical restraint/behavioral emergency medication administration), Staff #3 again explained that she doesn't. Staff #3 explained that to find that information out, she would have to go to each chart and review it. Staff #3 explained that she regularly received a list of medication administrations from pharmacy that could have been used during a behavioral emergency (chemical restraint/behavioral emergency medication administration). Staff #3 was asked to provide a copy of the medication list for the month of March and did so. The medication list provided information on medications transactions from the medication dispense machine (if a medication was removed from or placed back in the medication dispense machine using a specific patient name). The list included Haldol, Ativan, Zyprexa, and Geodon as these were identified as the most commonly used drugs during a psychiatric emergency.

During review of Patient #1's chart, it was discovered that restraints had been applied in response to the Patient #1 assaulting staff. Since the restraint log did not contain any information other than date a restraint was used, employee health reports were used to determine that 9 different staff members were injured by patient in 9 separate incidents:

2/26/2021 at 2:45 PM

3/2/2021 at 7:15

3/4/2021 at 11:50 PM

3/9/2021 at 3:00 AM

3/10/2021 at 4:05 PM

3/11/2021 at 1:50 PM

3/11/2021 at 9:55 PM

3/16/2021 at 3:30 AM

3/16/2021 at 9:45 AM

The patient was found to have skin wounds to his wrists from the prolonged use of wrist restraints and his fighting to get out of them.

Some of the restraints that were ordered during these violent outbursts were ordered as non-violent/medical restraints.

Staff #3 confirmed that, when auditing the chart for restraints, she audits based off of how the physician ordered it. If it was ordered as a non-violent/medical restraint, Staff #3 stated she would audit for the correct elements necessary for a non-violent/medical restraint even though it may have been ordered wrong. When asked why, Staff #3 explained that she has to go off of what the physician ordered.

A comparison of the medication list from Pharmacy and restraint log was made to identify patients who were placed in restraints and received medications that could have been used during a behavioral emergency because a patient was a danger to themselves and/or staff. Patient #7's chart was selected and reviewed as follows:

Patient #7 had been admitted after an intentional overdose of medications. Patient #7 also had a minimally displaced fracture of the right ankle as identified by X-Ray report from the afternoon of 3/4/2021. No documentation of the type of splint being used was found. No orders were found for the nursing care/precautions required for the fractured ankle and/or splint. Nursing notes from 3/4/2021 documented:

1:30 PM "Patient anxious and agitated. Patient removing oximetry monitor and BP cuff. Pateint instructed to leave devices in place and their importance. Patient states " they hurt, I feel horrible." Pt requiring frequent reminders and is unable to meet learning" (sic)

8:36 PM "Patient became very anxious and aggressive trying to get out of the bed, patient pulled off nasal cannula, attempted to pull off iv, started screaming and yelling. After failed redirection attempts Soft wrist restraints applied, sitter remains at bedside. Will continue to monitor."

Physician orders documented on 3/4/2021: 8:30 PM "Non-violent Medical Wrists - Disrupting Medical /Surgical Treatment Harm to Self Line Removal Attempt"

Nursing notes from 3/4/2021 documented: 11:41 PM "Patient became very aggressive yelling kicking screaming after asking for a bed pan. Writer went to assist with toileting and hygiene. Patient kicked writer. At this time decision was made to apply soft restraints to both ankles. Also received PRN order for Haldol IM. Meds given and patient cleaned as well as bed linen and gown changed. Vital signs stable. Will continue to monitor."

Physician orders documented on 3/4/2021: 10:56 PM (almost an hour prior to nursing record) Haldol 5 milligrams intramuscular every 6 hours as need for agitation, first dose now.

Review of the original list of medications from Pharmacy showed that a nurse removed the Haldol on 3/4/2021 at 11:15 PM against Patient #7's name and account number. This medication was not found to be documented as administered in the medication administration records. It could not be determined if the nurse who made the note that the patient received a dose of Haldol was the one to administer it, or the nurse who removed the medication from the medication dispense machine was the one who gave it. It was clear that the patient received the medication because she became violent and assaulted/kicked the nurse.

Review of physician orders from the timeframe of the behavioral emergency when the patient became a danger to staff showed that no order for bilateral ankle restraints was obtained for the Violent/Behavioral Restraint that was used. When the nurse completed patient care that placed her in proximity of being kicked by the patient, the ankle restraints were not removed. The Nursing Assessment Restraints section of the medical record showed that the patient remained tied to the bed by her wrists and ankles without a physician order for ankle restraints on:

3/4/2021 at 11:00 PM with no documented reasons for the ankle restraints applied or documentation of who actually applied the restraints;

3/5/2021 at 1:00 AM for the documented violent/behavioral reason that the patient was a "Harm to Others, Harm to Self" as well as the non-violent/medical reason that the patient attempted to remove lines and had no safety awareness.

3/5/2021 at 3:00 AM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 5:00 AM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 7:00 AM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 9:00 AM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 11:00 AM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 1:00 PM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 2:27 PM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 4:00 PM for the reasons "Harm to Self, Line Removal
Attempt"

3/5/2021 at 7:00 PM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 9:00 PM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 11:00 PM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/6/2021 at 1:00 AM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/6/2021 at 3:00 AM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/6/2021 at 7:00 AM the nurse charted in the Assessment Nursing Restraints, "restraints off at this time, sitter at bedside"


Restraints remained off until 3/6/2021 at 7:00 PM, the Assessment Nursing Restraints was documented that soft wrist restraints were in use and all 4 bedrails were being used as a restraint. A physician order had been entered on 3/6/2021 at 6:00 AM for "Restraint, nonviolent/medical wrists, both bed rails x 4 - Disrupting Medical /Surgical Treatment Harm to Self Line Removal Attempt". However, that order ended at 7:00 AM when the nurse removed the patient from restraints. No new order was obtained at 7:00 PM for restraints. The chart did not reflect what had happened at 7:00 PM that changed from the patient remaining restraint free the previous 12 hours to suddenly requiring restraints be placed again.

The patient record reflected, the patient remained in restraints without a physician order at:

3/6/2021 at 7:00 PM, 8:00 PM, 11:00 PM

3/7/2021 at 1:00 AM, 3:00 AM, 5:00 AM

The next documentation of restraints in the Assessment Nursing Restraint section of the chart was on 3/7/2021 at 9:00 PM showing that the patient was in wrist restraints and ankle restraints. No documented reason for the patient being in restraints was found. No documentation was found of who initiated the restraints.

An order had been placed on 3/7/2021 at 09:21 AM for "Restraint, Non-Violent/Medical. Four Point Bed Rails x 4 Disrupting Medical/Surgical Treatment Harm to Self Line Removal Attempt". There was no associated assessment found at the time of the restraint order to show that the patient needed to be placed in restraints at 9:21 AM. There was no record that restraints had been used between 9:21 AM and 9:00 PM making the 9:21 AM order no longer valid. A new order should have been obtained at the time restraints became necessary at 9:00 PM. No documentation was found to show that was done.


Patient #7 remained tied to the bed by her wrists and ankles without a valid physician order for:

3/7/2021 at 9:00 PM with no documented reason for restraints

3/7/2021 at 11:00 PM with no documented reason for restraints

On 3/8/2021 at 1:00 AM and 3:00 AM the nurse documented "Restraint NB every 2 hr interventions" and "Restraints Assess/Monitor" but did not document the type of restraints in use or the reason they were applied. At 5:00 AM the nurse documented that both wrist and ankle restraints were still being used. No reason for use was documented.

3/8/2021 at 5:00 AM was the last documented use of restraints in the Assessment Nursing Restraint section of the chart. Review of the Physical Therapy Progress Note for 3/8/2021 at 3:50 PM documented, "Pt was supine in bed, 4 point restraints donned, and sitter at bedside. Pt has c/o slight pain but did not specify location. Pt NWB on RLE. Pt agreeable to therapy. PT Duration: 2:59-3:35 pm" and "Pt tolerated session well. pt's mobility is improving. Pt left in supine with call light and needs in reach, restraints intact, RN at sitter at bedside. Pt has potential to improve with continued skilled therapy to address deficits."

Because the Quality Department did not have staff that understood the difference between the Violent and/or Behavioral Restraints and the Non-Violent and/or Medical restraints, the facility was unable to capture data about when a restraint was incorrectly ordered, applied, and monitored. Quality was not capturing data on when the patient was released from restraints and ensuring that a new order was obtained if the patient had to be placed back into restraints. Quality was not capturing data on when psychotropic medications were being given when a patient was determined to be a danger to self, staff, and others (chemical restraint/emergency behavioral medication administration).


Review of the policy titled Non-violent/Medical-Restraints-NS, policy number 66872.3, approval and effective date 10/16/2020 was made as follows:

"Reducing the use of Restraint through Performance Improvement

1) The organization will make all reasonable efforts to reduce the use of restraints. To accomplish this, a performance improvement process occurs.

2) This process may include, but not necessarily be limited to:

a) Collecting data

b) Compiling data

c) Analyze and compare the data over time to identify levels of performance patterns, trends, and variations

d) Use the result of its data analysis on the use of restraints to identify opportunities to improve

e) Take action on its improvement priorities and evaluate changes to confirm they resulted in improvements

3) Collect Specific Data related to the use of restraints to address violent (behavioral)/non-violent (medical) behavior

a) The shift during which the episode begins

b) The setting/unit/location where the episode occurs

c) The staff who initiated restraint

d) The length of each episode

e) The date and time each episode is initiated

f) The day of the week each episode is initiated

g) The type of restraint used

h) Any injuries sustained by the patient or staff

i) A patient identifier such as a Medical Record Number or Account Number

j) The patient age

k) The patient gender

l) Prolonged episodes of restraint"


While the restraint policy states a Performance Improvement Process is to occur, the policy did not identify who would be responsible for ensuring the Performance Improvement Process took place. The Performance Improvement Committee Meeting Minutes for the previous quarter (11/10/202, 12/8/2020, and 1/12/2021) were reviewed. Based on the minutes of the meetings, no information was presented regarding the Performance Improvement Process related to "Reducing the use of Restraint through Performance Improvement". Staff #3 verified that the information required to be collected by the policy was not being collected. The only project the Quality Department was doing was random sample audits of restraint charts.

Because the Quality Assessment/Process Improvement Department was not collecting, compiling, and analyzing data, the facility was unaware of the significant problems with restraint usage in the hospital. Patient #1 assaulted 9 staff members over an 18-day period with multiple restraints ordered and psychotropic medications ordered during his month-long stay without the Quality Department becoming alerted.

Based on record review and interview, the facility failed to recognize that medications administered to restrain a patient behavior, resulting in restricting the patient's freedom of movement, was a Chemical Restraint/Emergency Behavioral Medication (EBM) administration and was prohibited to be written as a PRN (as needed) order in 1 of 1(#1) patient charts reviewed.

The facility failed to ensure patient safety when administering sedative and psychotropic medications to control immediate behavioral emergencies. The facility failed to recognize emergency behavioral medications were chemical restraints and not therapeutic treatment in 1 of 1 (#1) patient charts reviewed.

The facility also failed to ensure staff conducted comprehensive patient assessments with escalation of behavior to determine patient needs and interventions prior to the administration of chemical restraints/emergency behavioral medication, and continuous monitoring after administering a chemical restraint/emergency behavioral medication for side effects, respiratory or cardiac distress, and assessment of medication effectiveness and safety after administration in 1 of 1 (#1) patient charts reviewed.

The facility failed to ensure a face to face evaluation was conducted following the administration of a chemical restraint/emergency behavioral medication to 1 of 1 (#1) patient charts reviewed. The face to face evaluation should be conducted within 1 hour of the restraint to determine the patient's immediate situation, patient's response to the restraint, and patient's medical and behavioral condition.

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.

Review of Patient #1's chart revealed he was taken by ambulance to the Emergency Room (ER) on 2/16/21 at 16:35 (4:35PM). Review of the ER Physician Notes dated on 2/16/21 at 16:35 (4:35PM) stated, "Patient stated complaint PSYCH, Narrative of Presenting Problem 31 y/o M with a hx of schizophrenia presents to the ED from ____ Group home c/o aggressive behavior x 1 hour. Pt was being more combative than normal, so EMS was called. EMS states that the pt's father reported that the pt was drooling that is new for him. Pt's father states he would like the pt to be placed in a psychiatric facility, specifically _____ (State Hospital) Pt. denies any sx." (SIC).

Patient #1 was examined by the ER physician and medically cleared for discharge. Review of the Nurses Notes dated 2/16/21 at 20:16 (8:16PM) stated, "Called ____ (State Hospital) regarding patient. Spoke with ____ (hospital employee) and was told that patient would need a crisis screening and then put on the waiting list at this time. 20:17 (8:17PM) Called and spoke with Group home (phone number listed). They were unable to take patient back at this time due to his aggression towards other residents."

Review of the physician notes dated 2/17/21 at 06:38 (6:38AM) stated, "Patient was seen/examined after shift change. Patient remains without complaint. Patient remains on waitlist for placement and psych eval. Remains medically cleared."

Review of the ER Physician Notes dated 2/17/21 at 14:03 (2:03PM) stated, " ...After discussing the patients presentation and symptoms with the patient's father and recent group home it appears the patient has had significant change in his mental status and physical abilities as far as activities of daily living. I will admit him to the hospital for further workup including evaluation by neurology due to previous seizures and psychiatry for possible medication complications ... Final Diagnostic Impression Altered Mental Status, encephalopathy ... Admit decision time 2/17/21 14:04 (2:04PM)."

An interview was conducted with Patient #1's father on 3/19/21 at 5:45PM. The father stated Patient #1 was diagnosed with Asperger Syndrome with mental disorders. The father stated that Patient #1 was going to a day program to work for the last five years and was doing well on his medications and was living at home. Patient #1's father confirmed that Patient #1 had a childlike mentality and required supervision. The father stated Patient #1 started to have some intermittent behavioral out bursts "just out of the blue" and started to become aggressive. Patient #1 was admitted to the State Hospital and was there for 9 months. The father stated he was not allowed to see the Patient #1 because of Covid-19 restrictions at the state facility. The father was informed Patient #1 was going to a group home and found Patient #1 heavily sedated, drooling, in a wheel chair and confused. The father felt Patient #1 was over sedated. The father was also concerned that Patient #1 may have had some new neurological issues going on and needed to have an MRI. 911 was called and Patient #1 was taken to the ER.


According to ninds.nih.gov, "Asperger syndrome (AS) is a developmental disorder. It is an autism spectrum disorder (ASD), one of a distinct group of neurological conditions characterized by a greater or lesser degree of impairment in language and communication skills, as well as repetitive or restrictive patterns of thought and behavior. Other ASDs include: classic autism, Rett syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (usually referred to as PDD-NOS). Unlike children with autism, children with AS retain their early language skills.

The most distinguishing symptom of AS is a child's obsessive interest in a single object or topic to the exclusion of any other. Children with AS want to know everything about their topic of interest and their conversations with others will be about little else. Their expertise, high level of vocabulary, and formal speech patterns make them seem like little professors. Other characteristics of AS include repetitive routines or rituals; peculiarities in speech and language; socially and emotionally inappropriate behavior and the inability to interact successfully with peers; problems with non-verbal communication; and clumsy and uncoordinated motor movements.

Children with AS are isolated because of their poor social skills and narrow interests. They may approach other people but make normal conversation impossible by inappropriate or eccentric behavior, or by wanting only to talk about their singular interest. Children with AS usually have a history of developmental delays in motor skills such as pedaling a bike, catching a ball, or climbing outdoor play equipment. They are often awkward and poorly coordinated with a walk that can appear either stilted or bouncy."


Review of the History and Physical dated 2/17/21 at 1512 (3:15PM) revealed Patient #1 was a 31-year-old male admitted to the facility on 2/17/21 for Encephalopathy. Patient #1 had the following past medical history documented, "1. Seizure disorder, 2. Bipolar Disorder, 3. Schizophrenia, 4. Asperger's, 5. Anxiety, and 6. Hypertension. Assessment and Plan: 1. Encephalopathy with normal CT. Will obtain a Depakote and lithium level and have consulted both _____ (Psychiatry) and _____ (Neurology). We will defer management of psychiatric medications to _____ (Psychiatrist). 2. Gastroesophageal reflux disease. We will continue Protonix. 3. Deep venous thrombosis prophylaxis with sequential compression devices. Code status: Full Code. It is my opinion, he will require 2+ midnight stay for encephalopathy.


According to ninds.nih.gov "Encephalopathy is a term for any diffuse disease of the brain that alters brain function or structure ... Depending on the type and severity of encephalopathy, common neurological symptoms are progressive loss of memory and cognitive ability, subtle personality changes, inability to concentrate, lethargy, and progressive loss of consciousness."


Review of the Physician Orders revealed Patient #1 was ordered the following medications for aggression, agitation or behavioral outburst as follows:

2/26/21 at 17:28 (5:28PM) Olanzapine (Zyprexa) 10mg = 2 ml Intramuscular BID PRN Agitation. (antipsychotic) Discontinued on 3/5/21.

2/27/21 at 10:47AM Lorazepam (Ativan) 0.5mg = 0.25ml intravenously once PRN Anxiety STAT and then Routine. (sedative) Discontinued on 2/27/21

2/27/21 at 10:47AM Lorazepam (Ativan) 2mg = 1ml intravenously Q4H PRN Anxiety. (sedative) Discontinued on 3/9/21.

3/05/21 at 12:34PM Olanzapine (Zyprexa) 10mg = 2 ml Intramuscular daily PRN Severe Agitation. (antipsychotic) Discontinued on 3/9/21.

3/7/21 at 2:56AM Diphenhydramine (Benadryl) 25mg = 0.5ml intravenous one time STAT for 1 Doses. (antihistamine- sometimes used for sedation effects). Discontinued on 3/7/21.

3/7/21 at 17:09 (5:09PM) Lorazepam (Ativan) 1mg = 0.5ml intravenous once PRN Anxiety Stat and then routine. (sedative) Discontinued on 3/9/21.

3/7/21 at 17:09 (5:09PM) Haloperidol (Haldol) 2mg = 0.4ml intravenous Q2H PRN Agitation/Restlessness. (antipsychotic) Discontinued on 3/8/21.

3/8/21 at 13:43 (1:43PM) Haloperidol (Haldol) 5mg = 1ml intramuscular once PRN Agitation STAT then routine. (antipsychotic) Discontinued on 3/8/21.

3/8/21 at 13:43 (1:43PM) Haloperidol (Haldol) 5mg = 1ml (antipsychotic) intravenous Q2H PRN Agitation/Restlessness. Discontinued on 3/9/21.

3/8/21 at 13:50 (1:50PM) Diphenhydramine (Benadryl) 50mg = 1ml intramuscular one time STAT for 1 Doses. (antihistamine- sometimes used for sedation effects). Discontinued on 3/8/21.

3/8/21 at 13:43 (1:43PM) Lorazepam (Ativan) 2mg = 1ml intramuscular once PRN Anxiety Stat and then routine. (sedative) Discontinued on 3/8/21.

3/8/21 at 19:19 (7:19PM) Diphenhydramine (Benadryl) 50mg = 1ml intramuscular Q 6H PRN severe agitation. (antihistamine- sometimes used for sedation effects).

3/9/21 at 11:41 AM Haloperidol (Haldol) 5mg = 1ml intramuscular Q6H PRN Severe Agitation. (antipsychotic) Discontinued on 3/12/21.

3/9/21 at 11:41 AM Lorazepam (Ativan) 2mg = 1ml. Intramuscular Q6H PRN Severe Agitation (sedative)

3/9/21 at 11:41 AM Diphenhydramine (Benadryl) 50mg = 2 Capsules intramuscular Q 6H PRN severe agitation. (antihistamine- sometimes used for sedation effects). This order was written by the attending Resident. The order stated 2 capsules. Capsules would be given by mouth but was administered intramuscular. The nurse failed to get a clarification on this order by the physician to ensure clear directions on how the medication was to be administered.

3/11/21 at 11:45 AM Haloperidol (Haldol) 5mg = 1ml intravenous one time stat for 1 doses. (antipsychotic) Discontinued on 3/11/21.

3/11/21 at 11:45 AM Diphenhydramine (Benadryl) 50mg = 1ml intravenous one time STAT for 1 Doses. (antihistamine- sometimes used for sedation effects).

3/11/21 at 11:45 AM Lorazepam (Ativan) 2mg = 1ml intravenously one time STAT for 1 Doses. (sedative) Discontinued on 3/11/21.

3/11/21 22:08 (10:08PM) If needed, may repeat the Ativan/ Benadryl/Haldol administration after one hour. Verbal order.

3/17/21 at 18:45 (6:45PM) Haloperidol (Haldol) 10mg = 2ml intravenous one time for 1 doses. (antipsychotic) Discontinued on 3/17/21.


Review of Policy and Procedure "Violent/Behavioral- Restraint and Seclusion-NS" Policy Number :66071.1 stated, "Discussion of Chemical Restraints: 10 It is important to note that the use of chemical restraints for behavioral emergencies is expressly prohibited in the State of Texas on behavioral health units and in behavioral health hospitals."

The facility is licensed as an Acute Care Hospital and not a behavioral health Hospital. The facility does not have a behavioral health unit.


Review of Policy and Procedure "Violent/Behavioral- Restraint and Seclusion-NS" Policy Number :66071.1 stated, ...CMS's definition of a chemical restraint is: a drug or medication when it is used as a restriction to manage the patients behavior or restrict the patient's freedom of movement and is not a standard treatment or dosage for the patient's condition.

4) in addition, the regulation does not permit a drug or medication to be used to restrain the patient for staff convenience, to coerce or discipline the patient, or as a method of retaliation.

5) It is the facility's policy and practice to not use chemical restraints in any area of the hospital. That is, facility staff shall not order or administer drugs or medications:

(1) for the purpose of restraining or restricting a patient's behavior or movement that is

(2) not a standard treatment and dose for the individual's condition ... Texas Health and Human Services Commission Psychiatric Drug Formulary as a guideline because it provides a list of standard doses of psychotropic medications that may be used for emergency conditions such as anxiety, psychosis, and other behavioral signs and symptoms. When used in accordance with the drug formulary/ guidelines, emergency psychotropic medications are not "restraints" within the meaning of the regulation because they are a standard drug or treatment for the patient's condition ...

6) because emergency medications used to treat behavioral emergencies and administered in accordance with the regulations are not chemical restraints, they are not documented on any restraint form

7) see also, "Documentation of Emergency Medications Ordered/ Administered for Behavioral Emergency (Form)."


The Texas Health and Human Services Commission Psychiatric Drug Formulary was intended for state hospitals, state supported living centers and community mental health centers not acute care hospitals. The facility should be responsible for having their own formulary's and guidance in medication administration and use.


Review of Policy and Procedure "Violent/Behavioral- Restraint and Seclusion-NS" Policy Number :66872.3 stated, "Behavior related to a non-psychiatric medical condition or symptoms that indicate the need for an intervention to protect the individual from harm. a) Restraints necessary for the patient's well being in order to facilitate effective treatment when less restrictive measures have been determined to be ineffective. An example includes measures taken to protect the patency of essential IV lines or tubes."


An interview was conducted in the morning on 3/23/21 with Staff #2 and Staff #6 concerning the policy and procedures Violent/Behavioral- Restraint and Seclusion-NS and Non-Violent/Behavioral- Restraint and Seclusion-NS" Staff #6 confirmed that they were not aware of what the policy said or had an understanding of chemical restraints vs EBM administration. Staff #6 stated that she was not aware of the Texas Health and Human Services "Psychiatric Drug Formulary or what that even was." Staff #2 and Staff #6 confirmed that the policy needed to be rewritten in understandable and correct language for clear and safe processes. Staff #2 stated that she was not aware, nor could she provide the "Documentation of Emergency Medications Ordered/ Administered for Behavioral Emergency (Form)."


Review of patient #1's clinical notes dated 2/26/21 at 15:49 (3:49PM) stated, "patient became aggressive while being changed, attempting to hit nurses, grabbing and squeezing anything he can get a hold of. Explained to the patient that this is unacceptable behavior. Patient threw an empty water bottle at the patient care tech. 16:20 (4:20PM) paged Dr.____ (Staff #31 Hospitalist) regarding the patient's behavior."


Review of Patient #1's physician orders dated 2/26/21 at 17:28 (5:28PM) revealed an order for Zyprexa (antipsychotic) 10mg = 2 ml Intramuscular BID PRN Agitation.


Review of Patient #1's medication administration record (MAR) revealed the medication was given on 2/26/21 at 18:32 (6:32PM), 64 minutes after the order was received. There was no documentation that the patient was reassessed for current behavioral issues that could be deescalated or if the patient was medicated from his last outburst documented at 3:49PM, 1-1/2 hours later. There was no evidence that this behavior continued that would warrant an Intermuscular (IM) behavioral medication. There was no documentation that the patient was offered by mouth (p.o.) medication. There was no documentation of a face to face performed, patient assessment, or effectiveness of the medication after the injection. The only vital signs found on Patient #1 was at 8:48AM and 12:03PM and 2:19PM.

There was no further documentation that the Zyprexa IM administered was being used as part of the patient regimen to assist with functioning in the milieu for therapeutic reasons. The only documentation was for aggression and "unacceptable behavior."

Agitation is not a medical diagnosis but a symptom with many variables from feeling nervous and restless to combative. Not all agitation would require an individual to be medicated.


According to https://medlineplus.gov/ency/article/003212.htm Agitation by itself may not be a sign of a health problem. But if other symptoms occur, it can be a sign of disease. Agitation with a change in alertness (altered consciousness) can be a sign of delirium. Delirium has a medical cause and should be checked by a health care provider right away."

There was no agitation scale or physician order found that defined agitation and the multilevel of agitation that would require a chemical restraint. A registered nurse must follow physician orders that provide an objective (not requiring the nurse to use medical judgement to interpret symptoms) scale or scoring system for PRN medications to stay within their scope of practice. Nurses were having to use medical judgement to determine if a patient should be medicated based on a symptom and not objective parameters identified by the physician within the order.


According to the "TEXAS BOARD OF NURSING CHAPTER 217
LICENSURE, PEER ASSISTANCE AND PRACTICE RULE §217.11
Standards of Nursing Practice

The RN does not perform medical diagnosis or prescription of therapeutic or corrective measures, unless licensed as an advanced practice registered nurse."
Review of the Nursing Care Plan revealed there was no documentation concerning what the problem the patient was having, plan of care, the use or order of a physical restraint or chemical/EBM restraints, interventions, outcomes, goals or PRN medications ordered for Patient #1's behavioral outbursts.



Review of patient #1's clinical notes dated 2/27/21 at 10:00 AM stated, "patient noted to be with aggressive behavior and hitting staff. Patient throwing food and other objects at staff and spitting. Dr. ____ (Staff #31 Hospitalist) at the bedside and ordered restraints and Ativan 1 mg IV. Patient continues to be aggressive."

Review of the physician orders dated 2/27/21 at 9:43AM stated, "Lorazepam (Ativan) 1 MG=0.5Ml intravenously once PRN Anxiety stat and then routine. Review of the MAR revealed there were "no occurrences charted". There was no documentation found on why the nurse did not administer the medication.

Review of the physician orders dated 2/27/21 at 10:47 AM stated, "Lorazepam (Ativan) 0.5 MG=0.25 ml intravenously Q4H PRN Anxiety. Review of the MAR revealed the order was not documented as administered and was discontinued on 2/27/21 at 11:45am
.
Review of the Nursing clinical notes dated 2/27/21 at 11:45AM stated, "Dr. ____ (Staff #31 Hospitalist) called and informed that the patient was still very agitated and aggressive with staff." There was no documentation that Staff #11 RN had administered any p.o. medications, the Ativan 0.5mg ordered at 10:47AM, attempted any de-escalation techniques, requested a sitter, notified the family, ask for assistance, offered comfort measures such as food, fluids, or toileting.


Review of the physician orders revealed 2 more restraints were ordered for the patient as follows:

1) Review of the physician orders dated 2/27/21 at 11:46 AM Ativan 2 mg = 1mL IV Q4hrs PRN anxiety." Review of the MAR revealed the order was not documented as administered.

2) Review of the physician orders dated 2/27/21 at 10:46AM stated, "Restraint Non-Violent/Medical Wrists, Both Vest for disrupting medical/surgical treatment harm to others. No documentation that restraints were applied. There was no found documentation on why the orders were not followed, no orders found to discontinue the medication and physical restraints, or if the physician was aware.

Staff #31 ordered non-violent restraints for a violent behavior outburst. The physician and nurse failed to follow the policy and procedures for violent behavioral restraints. Patient #1 had no documented medical or surgical treatments that would require non/violent medical restraint application. There was documentation that the patient was a fall risk but there was no order for sitters to watch the patient to assist in preventing injuries.


Review of the Physician Follow UP Note written by Staff #31 Hospitalist dated 2/27/21 at 14:41 stated, "Unfortunate 31 year old male with psychiatric problems. He has become more awake during the weekend. Psychiatry has been following. Yesterday, the patient became agitated and was interrupting his care. Also swinging at the nurses. Psychiatry had the patient take Zyprexa 10mg IM. That did little to control his behavior. Today, he is resting quietly but has periods of agitation and interrupting his care becoming aggressive with nurses. PLAN:

1. We will start Ativan IV every 4 hours. Titrate to control agitation.

2. Non- behavioral restraints, so he does not interrupt treatment or climb out of bed.

3. Routine clozapine and Depakote."


Review of the medication orders revealed there was an order for an Intravenous (IV) flush of normal saline, for an established IV, but there were no orders for IV medications other than for administration of chemical restraints/EBM.

There was no physician documentation that the ordered Ativan 2 mg = 1mL IV Q4hrs PRN was used as a therapeutic medication for participating in the milieu but to control a behavioral outburst and agitation. The use of PRN drug or medication is prohibited if being used as a restraint to control aggressive behaviors.

Review of the assessment report dated 2/27/21 revealed Staff #9 LVN (Licensed Vocational Nurse) assessed and documented on Patient #1 at 18:50 (6:50PM). The nurse documented that the patient was "cooperative, impulsive. Actions Reassurance, Frequent monitoring, Orient to person place and time, comfort measures, reduce environmental stimuli, Offered Nutrition and/ Hydration, offered hygiene and elimination, bed/body alarm. There was no documentation found that Patient #1 was in mechanical restraints or had been in restraints.



Review of the MAR dated 2/28/21 revealed there were 2 doses of Ativan 2 mg IV prn for anxiety given at 12:05PM and 22:45 (10:45PM) for agitation.

Review of the Nursing assessment and clinical notes revealed there was no documented description of the patient's behavior on 2/28/21 that would require the patient to receive an IV sedation medication. There was no documentation of de-escalation, that p.o. medication was tried first, an assessment/reassessment of the medication effectiveness, or that a face to face was performed. The RN used medical judgement to determine if a patient should be medicated based on a symptom of agitation and not objective parameters identified by a physician.

Review of the Nursing Care Plan revealed there was no documentation concerning what the problem the patient was having, plan of care, the use or order of a physical restraint or chemical/EBM restraints, interventions, outcomes, goals or PRN medications ordered for Patient #1's behavioral outbursts.


Review of Policy and Procedure "Violent/Behavioral- Restraint and Seclusion-NS" Policy Number :66071.1 stated, "Face-To-Face Evaluation Requirements for Any Form of a Behavioral Restraint or Seclusion: 1) An individual in restraint or seclusion in response to a behavioral emergency must be evaluated face-to-face within: one hour of the initiation of the event. As authorized by statutory regulations and this policy, the physician may delegate the face-to-face evaluation to a registered nurse or physician assistant who has current demonstrated competency in the approved training course SAMA which includes how to assess medical and mental status issues. The face-to-face evaluation includes, but is not limited to, the assessment of the following: a) Individual's immediate situation (behaviors that lead to the restraint or seclusion) b) Individual's response to the restraint or seclusion c) Individual's medical and behavioral condition at the time of the face-to-face evaluation d) Need to continue or terminate the restraint or seclusion 2) The registered nurse who conducts the face-to-face assessment must not be the registered nurse who initiated or participated in the restraint or seclusion. The nurse conducting the face-to-face evaluation must contact the physician as soon as possible after the conclusion of the evaluation. If the registered nurse to whom the physician delegated the face-to-face evaluation determines, in his or her professional judgment, the physician should evaluate the individual due to circumstances that are outside the scope of the nurses' practice or expertise, the physician may be requested to conduct the face-to-face evaluation."


Review of the clinical notes dated 3/1/21 at 22:40 (10:40PM) stated, "Pt became agitated. Pt was throwing items in his room and pt was grabbing at nursing staff. Pt was given 2 mg of Ativan IV. Will continue to monitor. There was no documentation of de-escalation, that p.o. medication was tried first, or a face to face was performed. The nurse documented on 3/2/21 at 12:21AM, "pt. appears more calm now. Will continue to monitor." The RN used medical judgement to determine if a patient should be medicated based on a symptom of agitation and not objective parameters identified by a physician.

Review of Staff #30 Psychiatry Resident progress notes dated 3/1/21 at 22:04 (10:04PM) stated, "Per nursing, the patient has been doing better and although he required emergency medications on 2/26/21 for agitation he responded well to oral Zyprexa prn for agitation yesterday evening. Pt is unable to identify stressors leading to aggression and denied pain. Patient was compliant with medications overnight and medication side effects were not observed or reported.

Patient reported their mood as okay and mentioned he would like to return to his group home after discharge. Pt reported hearing voices of everything causing moderate distress. Patient denied current suicidal thoughts with intent or plan and homicidal ideation."


Review of the clinical notes dated 3/2/21 at 19:43 (7:43PM) stated, "Pt became very aggressive. Pt had kicked a PCA named _____ in the mouth. Pt was told not to kick or hit the staff. Pt then threw his food at me. Pt was given IV Ativan. I was assisted by nursing staff. Will continue to monitor."

Review of the MAR dated 3/2/21 revealed the Patient received Ativan 2 mg IV for anxiety however, the nurse described abusive behavioral aggression not anxiety for administration of a chemical restraint/EBM. There was no documentation of de-escalation, that p.o. medication was tried first, an assessment/reassessment of the medication effectiveness, or that a face to face was performed. The RN used medical judgement to determine if a patient should be medicated based on a symptom of agitation and aggression.



Review of Patient #1's MAR dated 3/3/21 at 18:37 (6:37PM) revealed Patient #1 was administered Zyprexa 10mg IM from a PRN order. There was no found documentation on why the patient received this medication. There was no documentation of de-escalation, that p.o. medication was tried first, an assessment/reassessment of the medication effectiveness, or a face to face was performed.

Review of the clinical notes dated 3/4/21 at 23:51 (11:51PM) stated, "Sonosite in room attempting to start PIV (peripheral IV) as nurse and charge nurse were unsuccessful in starting one. Pt. is allowing staff to attempt. New PIV 20G started on LFA." There was no nursing documentation found on why Patient #1 required an IV to be restarted or how it came out. There was no documentation that the physician was called, or an order had been written to restart the IV. There was no found documentation on why the patient needed an IV access. There were no other daily medications administered or test ordered that would require an IV. The only documented medication administered through the IV was normal saline to keep the IV patent and the administration of chemical restraints/EBM for staff convenience.



Review of Patient #1's MAR dated 3/5/21 at 10:00Am Patient #1 was given Zyprexa 10mg IM from a PRN order. There was no found documentation on why the patient received this medication. There was no documentation of de-escalation, that p.o. medication was tried first, assessment/reassessment of the medication effectiveness, or a face to face was performed.

Review of the Psychiatry Progress Notes dated 3/5/21 at 22:48 (10:48PM) Staff #36 Psychiatry Resident documented, "Patient has been agitated and aggressive lately. He was given Zyprexa IM, Ativan, Depakote, and Clozaril but he continued to attempt to hit staff members. Unable to interview the patient due to violent behavior towards nurse as she tried to approach him. Staff reports since his time here (Feb 17th) he has unchanged violent behavior that could last up to an entire shift until he accepted PRN medication for psychosis. After violent episodes, the patient would apologies and show remorse. The staff have had to restrain the patient to administer care. The patient is tolerating medications without adverse reactions."

Review of the Psychiatry Progress Notes dated 3/5/21 at 22:48 (10:48PM) Staff #36 Psychiatry Resident stated, "accepted PRN medication for psychosis" but Patient #1 was ordered an IM psychotropic medication with no documentation that the p.o medication was available. The physician continued to document that "the staff have had to restrain the patient to administer care" but was unclear on what care or if he was restrained to administer the medication.

An interview was conducted with Staff #15 CMO on 3/24/21. Staff #15 reported that the Psychiatrist and Psychiatric Residents were using telemed to do their visits. There was no documentation that the resident tried to come and see the patient in person but relied on the nursing staff, who was administering the chemical restraints/EBM, to describe the patient's behaviors.

An interview conducted with Staff #11 on 3/22/21 confirmed that the Psychiatric Residents used telemed when visiting Patient #1.



Review of patient #1's clinical notes dated 3/6/21 at 21:04 (9:04PM) Staff #10 LVN documented, "Pt agitated and aggressive. Tried to calm pt down and this was ineffective. Even with help of charge nurse. 2mg IV Ativan given. There was no documentation found on what "calm pt down" consisted of. There were no further de-escalation techniques documented. Pt had p.o. Ativan ordered but was not documented as offered.

Review of the Patient #1's MAR revealed he was administered Ativan 2mg IV from a PRN order that was written on 2/27/21. The RN documented the administration of the Ativan given IV on 3/6/21 at 21:04 (9:04PM).

Review of the Assessment Report Restraints dated 3/6/21 at 2:30AM revealed the RN documented that the patient was "agitated, no safety awareness, less restrictive alternatives ineffective, respirations even and unlabored. Attempting to get out of bed." No further documentation noted from the RN until 7:00AM.

Review of patient #1's clinical notes dated 3/6/21 at 22:46 (10:46PM) revealed the LVN documented, "Pt calmed down and was willing to take p.o. night medications. 23:45 (11:45PM) Pt requested vitals be taken. Pt calm during vital signs but when trying to remove BP cuff Pt got extremely agitated and combative (hitting, grabbing, and pushing)."


Review of Patient #1's clinical notes dated 3/7/21 at 3:00AM Staff #10 LVN documented, "Pt agitation continues to worsen combative, yelling, shaking bedrails, hitting, clawing, and grabbing. PCT went into room to turn off call light that had come on while Ativan was being drawn up. Pt grabbed PCT and would not let her go. Took three nurses to get pt to release PCT and 2 mg of Ativan was given. Restraints were pulled from supply locker and charge nurse initiated restraints at 3:30AM. Took 5 nurses to restrain pt to keep him from harming himself. Pt put in 4 point restraints due to wrist restraints not being adequate. Security was called due to 4 point still not being adequate and with the hel

Based on review of records and interview, the facility failed to ensure medical staff documented the rationale for using multiple types of restraints as being the least restrictive measure to protect the patient and others from harm in 2 (Patient #4 and Patient #7) of 2 patients reviewed. The facility failed to ensure that medical and nursing staff followed the facility policy and procedures put in place to ensure the least restrictive measures were used and documented with descriptions of behaviors.

Findings:

Review of Patient #4's Chart:

Patient #4 was an 85-year-old man who had previously lived independently. He had been using a wheelchair for approximately a month due to back problems and was scheduled for a surgery that required a post-surgical hospital stay. The patient had a history of depression that was treated with Tofranil.

Post-surgery, the following orders were placed for Non-Violent Restraint/Medical restraints for Patient #4:

3/5/2021 at 12:47 PM "Restraint, Non-Violent/Medical. Line Removal Attempt"

3/6/2021 at 13:44 PM "Restraint, Non-Violent/Medical. Wrists, Both Disrupting Medical/Surgical Treatment Climbing Out of Bed Line Removal Attempt"

3/7/2021 at 6:09 PM "Restraint, Non-Violent/Medical. Wrists, Both Ankles, Both Disrupting Medical/Surgical Treatment Harm to Self Line Removal Attempt"

3/8/2021 5:41 PM "Restraint, Non-Violent/Medical. Wrists, Both Ankles, Both Disrupting Medical/Surgical Treatment Harm to Self Line Removal Attempt"


Review of physician and nursing documentation associated with the restraints was as follows:

The chart reflected that the nurse placed the patient in restraints on 03/05/2021 at 1:20 PM. The order and nursing documentation did not indicate the type of restraints that were being used. The nurse documented, "Confused, Less restrictive alternatives ineffective, Respirations even and unlabored, Attempting to get out of bed". No explanation was made of interventions that had been attempted, considered, and the patient's response to those interventions other than "Reorient Frequently, Request Compliance" and "Sensory Interventions Appropriate Lighting, Appropriate Activity, Appropriate Noise". No explanation of what Appropriate Lighting, Activity, and Noise for this patient was, or if there was any indication that lighting, activity, and noise was an issue that needed to be addressed. The medical record reflected that the patient was post-surgery and had been experiencing pain, pulling at lines, and confused. No records were found that interventions related to these issues were discussed, considered, and failed in the nursing documentation or physician documentation.

Review of the facility's restraint log showed that the log did not contain information on types of restraints being used. The restraint log only showed the name of the patient and the date that restraints were used. An interview was conducted with Staff #3 on 3/22/2021 in the Administration Conference room. Staff #3 confirmed that the information presented to surveyors on the Restraint Log was the only information available for the log. In order to identify anything else, each patient chart would have to be individually reviewed. In the case of Patient #4, the chart did not reflect what type of restraints were initially ordered and initially applied. Therefore, the determination that the least restrictive intervention was employed could not be determined because the specific restraint intervention was not identified in the chart or on the restraint log. Staff #3 confirmed that the Quality Department was not monitoring restraints to ensure the least restrictive measures were being used.

The physician documentation from 03/05/2021 at 3:17 PM did not contain any information about the patient needing to be physically restrained. The physician documented, "Subjective Patient examined today and remained alert, afebrile, hemodynamically stable. Overnight he had bouts of severe anxiety state and agitation. He is much better today and still with issues of constipation and will continue with laxatives."

A nursing note from 03/05/2021 at 9:00 PM Purposeful Rounding Comment documented "Pt in bed, with soft wrist restraints on." On 03/06/2021 at 1:00 AM, the nursing documentation showed that Patient #4 was "in room sleeping with restraints on, pt talking in sleep and smiling showing no signs of pain." (sic) Patient was left in the restraints. At 5:00 AM, the record reflected that the patient had "wiggled out of restraints. Pt attempting to pull out foley, hitting and kicking staff. RN re-established restraints at this time."

The physician documented the following in a progress note on 03/06/2021 at 9:00 AM: "He is seen and examined today with his daughter at bedside and is alert, afebrile and hemodynamically stable. Staff reports overnight he became very agitated and attempting to move his lines and to elope. He is still a bit constipated will continue with MiraLAX daily. He is coughing with all his meals and such we will get speech-language pathology to assess and manage. Given his level of agitation I will start Seroquel at bedtime. He is also still quite agitated a time here now I will proceed in giving soft restraint due to his impulsivity."

While the documentation showed that the patient was agitated, impulsive, and pulling at lines, there was no documentation of less restrictive interventions such as hiding the lines, securing the lines by wrapping them so that the patient could not pull them, sitters at the bedside, etc. that had been considered but not appropriate or attempted and failed.

On 03/06/2021 at 9:34 PM nursing documentation stated that "Pt became very agitated at this time. Pt punched RN in stomach. Restraints adjusted and pt repositioned back in bed. Pt
pupils reactive and vitals stable." At 10:07 PM the Patient Care Assistant (PCA) documented the patient was "in bed tryin to get out restraints, pt trying pull on restraints to get foley (catheter that goes into the bladder to drain urine), im sitting outside door to watch my lights and keep and eye on pt." (sic) At 11:00 PM the nursing staff documented the patient was "agitated and verbally abusive to staff." On 03/07/2021 at 1:00 AM, nursing staff documented the patient was agitated and wanting to "get out of here".


On 03/07/2021 at 8:12 AM, the physician documented: "He is now with bouts of agitation and and (sic) new onset with mental status change in which she at times violent attack on the staff with hitting. Per his family this is very new for him since he is highly functional. I will discontinue all sedative-hypnotics. He is restrained and will try to relax of restraint. I will discontinue Foley catheter and check urine for any infection. He is able to get up with therapy and stand and as such we will continue current inpatient physical therapy and Occupational Therapy." (sic)

The physician orders for activity on 03/02/2021 was for the patient to advance activity as tolerated with assistance. No documentation was found as to why Patient #4 was being restrained in the bed instead of the facility providing the nursing staff required to assist the patient out of bed to a bedside chair, to a wheelchair, or taken for a walk while in a wheelchair. Instead, nursing staff continued to document the patient attempting to get out of bed as a reason he was restrained.

The Physical Therapy (PT) note from 03/07/2021 1:50 PM showed that "informed nsg pre-gait only and he is not ready to walk yet due to decreased assistance from pt and weakness in legs. back to supine at end of tx. nurse in room and request do not place wrist restraints on as she wants to see how he is doing, daughter will remain in room to monitor pt."

Nursing documentation from 03/07/2021 showed, "Restraints were put back on at 2:30 as patient was trying to get out of bed as a fall risk". At 4:03, nursing documentation showed that the patient was tied to the bed with "both wrist and ankle restraints". At 5:00 PM the chart reflected that the patient was in "4 point softs applied" (soft restraints around wrists and ankles tying the patient to the bed and limiting movement of the arms and legs) and "Additional NB Restraints Side Rails x 4" (all bed side rails raised to prevent the patient from exiting the bed) because the patient was "Climbing Out of Bed, Harm to Others, Line Removal Attempt, No Safety Awareness".

There was no documentation from nursing staff or physician staff found to explain the rationale for tying both legs to the bed and raising all of the bed rails to restrain the patient. No documentation was found to explain the behaviors that represented such an extreme danger to others that wrist restraints, leg restraints and bed rail restraints had to be used on Patient #4.

On 03/07/2021 at 4:46 the nurse obtained a telephone order from the physician for Haldol 5 MG (milligrams) IV (in the vein) to be given Q6H (every 6 hours) PRN (as needed), Agitation/Restlessness First Dose Now.


Per the Food and Drug Administration (FDA) website, Haldol has only been approved for the following indications: "HALDOL (haloperidol) is indicated for use in the treatment of schizophrenia. HALDOL is indicated for the control of tics and vocal utterances of Tourette's Disorder"

Use of Haldol was also identified as having risk for sudden death, dangerous changes in the heart functioning (QT-prolongation and Torsades de Pointes) and was not approved for IV use. The warning was as follows:

"Cardiovascular Effects
Cases of sudden death, QT-prolongation, and Torsades de Pointes have been reported in patients receiving HALDOL. Higher than recommended doses of any formulation and intravenous administration of HALDOL appear to be associated with a higher risk of QT-prolongation and Torsades de Pointes. Although cases have been reported even in the absence of predisposing factors, particular caution is advised in treating patients with other QT-prolonging conditions (including electrolyte imbalance [particularly hypokalemia and hypomagnesemia], drugs known to prolong QT, underlying cardiac abnormalities, hypothyroidism, and familial long QT-syndrome). HALDOL INJECTION IS NOT APPROVED FOR INTRAVENOUS ADMINISTRATION. If HALDOL is administered intravenously, the ECG should be monitored for QT prolongation and arrhythmias."

https://www.accessdata.fda.gov/drugsatfda_docs/label/2008/015923s082,018701s057lbl.pdf

The patient did not have a history of schizophrenia or Tourette's Disorder. The patient was not connected to a cardiac monitor to monitor his heart rhythm (ECG-electrocardiogram) while receiving IV Haldol.

Review of the Medline Plus website was as follows: https://medlineplus.gov/ency/article/003212.htm

"Agitation
Agitation is an unpleasant state of extreme arousal. An agitated person may feel stirred up, excited, tense, confused, or irritable.

Considerations
Agitation can come on suddenly or over time. It can last for a few minutes, for weeks, or even months. Pain, stress, and fever can all increase agitation.

Agitation by itself may not be a sign of a health problem. But if other symptoms occur, it can be a sign of disease.

Agitation with a change in alertness (altered consciousness) can be a sign of delirium. Delirium has a medical cause and should be checked by a health care provider right away."


The physician order was written for "Haldol 5 MG IV to be given Q6H PRN Agitation/Restlessness First Dose Now."


While there is an objective scale of agitation developed for patients that are sedated, there is not one for patients who are not sedated. There were no objective criteria or scale that distinguished what agitation was. This required the nurse to assess the patient and decide when to medicate the patient without objective guidelines. Based on the order parameters, the patient could have been medicated for shouting at the staff or demanding that he wanted to go home. Without objective parameters, the nurse must decide what agitation means to the nurse and what behaviors to give medication for every 6 hours without a physician assessment of the behaviors to ensure something hasn't medically changed and the least restrictive intervention was used. As Haldol has no reversal agent, once given, the patient must wait for the effects to wear off. No rationale was found documented in the chart for why the medication was chosen to control behaviors for which the patient was already being mechanically restrained.

The medical record showed that the nurse gave the Haldol on 03/07/2021 at 5:48 PM for the reason, "Agitation". The nurse gave the Haldol on 03/08/2021 at 3:16 PM for the reason, "Anxiety" which was not one of the PRN reasons listed on the original order for giving the medication. No record of a nursing assessment that documented the need for Haldol was found prior to the medication given on 03/07/2021. Nursing documented the following on 03/07/2021 at 3:15 PM, prior to giving the Haldol. "Patient recieved PRN Hadol (sic) for anxiety. Patient is restless; uncooperative with safety protocols. Patient is trying to get out of bed. Hyperventilating. Sitter @ bedside."

The medication administration record did not contain a record of a follow-up assessment and patient response to the medication after it was given. On 03/07/2021 at 5:30 PM the nurse charted, "Patient is continously restless even after PRN Hadol for anxiety & efforts to relax patient have failed. MD notified. Orders for sitter are in place & restraints if sitter is unavailable. Orders not to use simaltaneously. PRN Hadol 5 mg changed to Q4 hrs. & Ativan 1 mg ordered Q 4hrs." (sic)

The physician progress note from 03/08/2021 did not address the use of Haldol to control the patient's agitation. The Assessment and Plan from the progress note listed item number 7: "Altered Mental Status, Present On Admit No, Clinical Status New, with Sun Downing, UA C&S" (urinalysis with culture and sensitivity to check for infection).

Sun Downing was defined by MayoClinic.org as "The term "sundowning" refers to a state of confusion occurring in the late afternoon and spanning into the night. Sundowning can cause a variety of behaviors, such as confusion, anxiety, aggression or ignoring directions. Sundowning can also lead to pacing or wandering. Sundowning isn't a disease, but a group of symptoms that occur at a specific time of the day that may affect people with dementia, such as Alzheimer's disease. The exact cause of this behavior is unknown."


Review of Patient #7's Chart

Patient #7 was a 58-year-old female who had been admitted after an intentional overdose of medications. Patient #7 also had a minimally displaced fracture of the right ankle as identified by X-Ray report from the afternoon of 3/4/2021.


The following orders were placed for Non-Violent Restraint/Medical restraints for Patient #7:

3/4/2021 at 8:30 PM Non-violent Medical Wrists - Disrupting Medical /Surgical Treatment Harm to Self Line Removal Attempt

3/5/2021 at 6:00 AM Restraint, nonviolent/medical wrists, both bed rails x 4 - Disrupting Medical /Surgical Treatment Harm to Self Line Removal Attempt

3/6/2021 at 6:00 AM Restraint, nonviolent/medical wrists, both bed rails x 4 - Disrupting Medical /Surgical Treatment Harm to Self Line Removal Attempt

3/7/2021 at 09:21 AM Restraint, Non-Violent/Medical. Four Point Bed Rails x 4 Disrupting Medical/Surgical Treatment Harm to Self Line Removal Attempt

3/8/2021 at 1:35 PM Restraint, Non-Violent/Medical. Four Point Bed Rails x 4 Disrupting Medical/Surgical Treatment Harm to Self Line Removal Attempt

3/9/2021 at 10:15 AM Restraint, Non-Violent/Medical. Four Point Wrists, Both Harm to Self Line Removal Attempt


Review of physician and nursing documentation associated with the restraints was as follows:

The initial History and Physical was completed on 03/03/2021 at 8:28 AM by the resident. A supervisory note stating that the supervising physician had "personally examined the patient and agree with the details as documented by the resident physician." Additional notes were added by the supervising physician. No documentation of an ankle fracture or splint was found in the initial History and Physical.

No documentation of the type of splint being used was found. No orders were found for the nursing care/precautions required for the fractured ankle and/or splint. No orders were found for patient activity level permitted such a bed rest, bed rest with bathroom privileges, activity as tolerated, or non-weightbearing to the right lower extremity due to fracture and splint
On 03/03/2021 at 7:00 PM the nursing assessment noted a splint to the Right Lower Extremity.

An X-Ray of the right ankle was taken on 03/04/2021 at 12:11 PM. The report was dictated, transcribed and electronically approved by 2:37 PM the same day. The X-Ray showed a "minimally displaced" right ankle fracture and a fracture of a bone in the right foot.

Review was made of the Hospitalist Progress notes. The progress notes all contained the same information about the patient's fractured ankle with the exception of the discharge summary on 3/11/2021. The notes were as follows"

3/5/2021 at 5:30 PM Orthopedics consulted, recommendations for f/u OP
Continue splint

3/6/2021 at 8:51 AM Orthopedics consulted, recommendations for f/u OP
Continue splint

3/7/2021 at 1:00 PM Orthopedics consulted, recommendations for f/u OP
Continue splint

3/8/2021 at 7:10 AM Orthopedics consulted, recommendations for f/u OP
Continue splint

3/9/2021 at 7:03 AM Orthopedics consulted, recommendations for f/u OP
Continue splint

3/10/2021 at 8:10 AM Orthopedics consulted, recommendations for f/u OP
Continue splint

3/11/2021 at 11:22 AM Orthopedics consulted with recommendations for splinting and follow up to outpatient orthopedics for further evaluation of her RLE fractures.

No orders were ever found for an orthopedic consult in relation to the new finding of a minimally displaced right ankle fracture. No orthopedic physician consult note was found in the chart identifying the Orthopedic Physician who had been consulted and documenting the results of the Orthopedic Physician's review of findings and consultation recommendations. No orders were found regarding the type of splint or care of the right lower extremity while in the splint.


On 03/04/2021 at 3:30 PM the nurse charted, "Patient anxious and agitated. Patient removing oximetry monitor and BP cuff. Pateint instructed to leave devices in place and their importance. Patient states " they hurt, I feel horrible." Pt requiring frequent reminders and is unable to meet learning" (sic)

At 8:36 PM the nurse charted, "Patient became very anxious and aggressive trying to get out of the bed, patient pulled off nasal cannula, attempted to pull off iv, started screaming and yelling. After failed redirection attempts Soft wrist restraints applied, sitter remains at bedside. Will continue to monitor."

At 11:41 PM, the nurse charted, "Note: Patient became very agressive yelling kicking screaming after asking for a bed pan. Writer went to assist with toileting and hygiene. Patient kicked writer. At this time decison was made to apply additional soft restraints to both ankles. Also received PRN order for Haldol IM. Meds given and patient cleaned as well as bed linen and gown changed. Vital signs stabe. Will continue to monitor." (sic)


Review of the chart showed that ankle restraints were used until 03/08/2021 at 5:00 AM with the exception of intermittent periods when restraints were removed all together. At times, all 4 bed rails were up to prevent the patient from exiting the bed. The restraints were ordered in response to the patient's violent behavior. However, the orders were put into the computer as non-violent/medical restraints.


Review of the physician progress notes and nursing notes did not contain documentation of the rationale for tying the patient's arms and legs to bed with soft wrist and ankle restraints, putting all four bed rails up, and medicating the patient with Haldol due to her violent behaviors associated with her agitation. The initial ankle restraints were placed when the nurse was kicked trying to provide the patient with care. No documentation was found from the nurse or physician about the care of the ankle fracture in relation to placing restraints around an ankle with a newly diagnosed ankle fracture. The ankle restraints were left in place after the nurse completed her care and was no longer in proximity to be kicked. This was also when the order for Haldol was obtained.


The order for Haldol was started on 3/4/2021 at 8:56 PM. It was administered on 3/5/2021 at 5:12 AM; 3/5/2021 at 1:45 PM; 3/7/2021 at 7:39 AM; and 3/8/2021 at 5:44 AM. The order was stopped on 3/8/2021 at 1:39 PM. None of the medication administrations had documentation on the Medication Administration Record of a re-assessment and patient response to the medication. Discussion of the risks of drugs, use to treat agitation, and requirement of nursing staff to use medical judgement in deciding when to administer for agitation was above under review of Patient #4's chart.

Review of the order showed that the physician had placed an order on 3/7/2021 at 7:44 AM for Geodon 20 milligrams to be injected into the muscle as needed every 4 hours for "anti-psychotic".

The nurse administered the medication at 8:03 AM for the reason, "anti-psychotic". No documentation was found of the behaviors the nurse assessed as "anti-psychotic" indicating the need for the PRN Geodon to be given. No follow-up assessment or patient response to the medication was documented on the Medication Administration Record.

Further review of physician documentation showed that this medication had been ordered in response to the patient becoming aggressive and violent with staff, indicating that this medication was given to control the patient's violent behavior rather than treat a psychiatric or medical condition.

On 3/7/2021 at 1:00 PM the physician documented, "Subjective Patient seen and examined this morning. She is much more aggressive today compared to yesterday. She is trying to hit nursing staff and yelling for family member names. Sitter reports patient has been restless and not slept in three nights. She denies any issues but not reliable."


The physician identified the plan as, "#Agitation/possible withdrawal Ativan 1mg PRN, haloperidol PRN, Geodon PRN continue 4 pt restraints for now". As with Patient #4, no rationale was found for why the medication was chosen to control behaviors for which patient was already being mechanically restrained.


Further review of physician and nursing staff documentation did not include information/rationale on the use of ankle restraints for a patient who was kicking and had a minimally displaced ankle fracture while in a splint. The documentation did not discuss the type of splint being used; if the splint was sufficient enough to prevent further damage to the ankle fracture while kicking/fighting while having the right lower extremity tied down by the fractured ankle; if an orthopedist had reviewed the use of ankle restraints and approved or was given the opportunity to make modifications to the plan of care for safety; or less restrictive interventions to tying down the right lower extremity by the ankle that had been attempted and failed or considered and rejected as not being appropriate.

Review of the policy titled Non-violent/Medical-Restraints-NS, policy number 66872.3, approval and effective date 10/16/2020 was made as follows:

"Policy:
...
2) Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time.
...
4) The decision to use a restraint is not driven by diagnosis, but by a comprehensive individual patient assessment. This comprehensive individual patient assessment is used to determine whether the use of less restrictive measures poses a greater risk than the risk of using a restraint. The comprehensive assessment should include a physical assessment to identify medical problems that may be causing behavior changes in the patient.

5) Restraints may only be employed while the unsafe situation continues. Once the unsafe situation ends, or the patient's needs have been addressed using less restrictive methods, the decision to discontinue use of restraints should be made by an RN or physician.

6) The use of restraint for the management of patient behavior should not be considered a routine part of care. The use of restraints for the prevention of falls should not be considered a routine part of the falls prevention program.
...

Procedures:

1) Initial Orders for Non-Violent Restraint/Medical
...
a) v) The least restrictive, safe and effective method of restraint is to be used. The type and technique used must be the least restrictive intervention that will be effective to protect the patient or others from harm.

a) vi) Restraint use should be discontinued when there is no longer adequate and appropriate justification for continued use and before an order expires. The use of restraints must be discontinued as soon as possible based on an individualized patient assessment and re-evaluation. Temporary release for caring for a patient is okay (feeding, ROM [range of motion], toileting). A trial release is a PRN order and not permitted.
...
3) Monitoring and Documentation

a) Upon initiation and release
...
vii) Description of the patient's behavior

viii) patient's condition or symptom(s) that warranted the use of restraints

ix) Patient's response to less restrictive alternatives"


The facility failed to ensure that medical and nursing staff followed the facility policy and procedures put in place to ensure the least restrictive measures were used and documented with descriptions of behaviors





.

Based on review of records and interview, the facility failed to ensure written modifications were made to the patient's plan of care when restraints were used for 2 (Patient #4 and Patient #7) of 2 patient care plans reviewed. The Plan of Care did not include the types of restraints used, time limits for use, long-term goals/outcomes, or short-term goals/outcomes.

Findings:

Review of Patient #4's chart:

The following orders were placed for Non-Violent Restraint/Medical restraints for Patient #4:

3/5/2021 at 12:47 PM Restraint, Non-Violent/Medical. Line Removal Attempt

3/6/2021 at 13:44 PM Restraint, Non-Violent/Medical. Wrists, Both Disrupting Medical/Surgical Treatment Climbing Out of Bed Line Removal Attempt

3/7/2021 at 6:09 PM Restraint, Non-Violent/Medical. Wrists, Both Ankles, Both Disrupting Medical/Surgical Treatment Harm to Self Line Removal Attempt

3/8/2021 5:41 PM Restraint, Non-Violent/Medical. Wrists, Both Ankles, Both Disrupting Medical/Surgical Treatment Harm to Self Line Removal Attempt

The restraint orders did not contain specific time frames for restraints to be used. Time frames were not incorporated into the patient Plan of Care. No identification of specific outcomes or goals along with criteria for release were found in the orders or the plan of care.

A section of the chart identified as the Plan of Care Report was reviewed. No identifiable Plan of Care for restraints was found in the chart. A sub-section labeled "Problems associated to Selected Visit" listed the following problems:

Pain
Assigned 03/03/2021 4:28 PM

Disrupting Treatment / No Safety Awareness
Assigned 03/05/2021 12:49 PM

Review of the section identified as "Expected Outcomes" did not contain any expected outcomes related to the use of restraints.

Review of Patient #7's chart:

The following orders were placed for Non-Violent Restraint/Medical restraints for Patient #7:

3/4/2021 at 8:30 PM Non-violent Medical Wrists - Disrupting Medical /Surgical Treatment Harm to Self Line Removal Attempt

3/5/2021 at 6:00 AM Restraint, nonviolent/medical wrists, both bed rails x 4 - Disrupting Medical /Surgical Treatment Harm to Self Line Removal Attempt

3/6/2021 at 6:00 AM Restraint, nonviolent/medical wrists, both bed rails x 4 - Disrupting Medical /Surgical Treatment Harm to Self Line Removal Attempt

3/7/2021 at 09:21 AM Restraint, Non-Violent/Medical. Four Point Bed Rails x 4 Disrupting Medical/Surgical Treatment Harm to Self Line Removal Attempt

3/8/2021 at 1:35 PM Restraint, Non-Violent/Medical. Four Point Bed Rails x 4 Disrupting Medical/Surgical Treatment Harm to Self Line Removal Attempt

3/9/2021 at 10:15 AM Restraint, Non-Violent/Medical. Four Point Wrists, Both Harm to Self Line Removal Attempt

The restraint orders did not contain specific time frames for restraints to be used. Time frames were not incorporated into the patient Plan of Care. No identification of specific outcomes or goals along with criteria for release were found in the orders or the plan of care.

A section of the chart was identified as the Plan of Care Report. A sub-section labeled Plan of Care was documented as Last Reviewed Date of 3/9/2021 at 07:06 by a nurse. This section included the following "Standard Name" and "Date Assigned"

Skin Integrity Impairment Risk 03/06/2021 05:12
Restraints 03/06/2021 05:12
Fall Risk 03/06/2021 05:12
Fall 03/06/2021 05:12
Disrupting Tx/No Safety Awareness 03/06/2021 05:12

Other than the nurse that assigned these Standard Names, no additional information was provided in this section to explain what the Standard Names were to be used for or the patient care associated with these.

The next section identified "Problems associated to Selected Visit" with the following fields and their content:

Problem Name: Drug-induced Hypotention; Date Assigned: 3/3/2021 05:58 (5:58 AM);

The next section identified "Problems associated to Patient" with the following fields and their content:

Problem Name: Respiratory Failure
Date Assigned: 3/3/2021 01:55 (1:55 AM);

Problem Name: Acute Kidney Injury
Date Assigned: 3/3/2021 01:55 (1:55 AM);

Problem Name: Altered Mental Status
Date Assigned: 3/3/2021 01:55 (1:55 AM);

Problem Name: Intentional Drug Overdose
Date Assigned: 3/3/2021 01:55 (1:55 AM);

Problem Name: Hypoglycemia
Date Assigned: 3/3/2021 01:55 (1:55 AM);

Problem Name: Acute Hypoxic Respiratory Failure
Date Assigned: 3/3/2021 05:58 (5:58 AM);

Problem Name: Acute Kidney Injury
Date Assigned: 3/3/2021 05:58 (5:58 AM);

Review of the section identified as "Expected Outcomes" did not contain any expected outcomes related to the use of restraints.


Review of the policy titled Non-violent/Medical-Restraints-NS, policy number 66872.3, approval and effective date 10/16/2020 was made as follows:

"Procedure:
1) Initial Orders for Non-Violent Restraint/Medical
...
iv) The use of restraint must be in accordance with the written modification to the patient's Plan of Care; and implemented in accordance with safe and appropriate restraint techniques."

Based on review of records, the facility failed to ensure that restraints were only initiated and continued with complete physician orders for 3 (Patient #1, #4 and Patient #7) of 3 patients reviewed. Nursing staff initiated and continued restraints without obtaining or verifying a valid physician order.

These deficient practices were determined to pose an Immediate Jeopardy to the health and safety of patients that had the likelihood to cause harm, serious injury, impairment and/or subsequent death.

Findings:

Review of Patient #4

Patient #4 had been admitted after a scheduled surgical procedure on his back. He had previously lived alone and independently performed all activities of daily living. The patient did not have a history of psychiatric conditions or dementia.

Physician Orders and Nursing Documentation were reviewed as follows:

Order 3/5/2021 at 12:47 PM "Restraint, Non-Violent/Medical. Line Removal Attempt"

This order was placed by the nurse and had not been authenticated by the physician at the time of survey. The order was placed for a Non-Violent/Medical restraint but did not specify the type of restraint to be used, making it an incomplete order.

Review of the Assessment Nursing Restraints section of the chart showed that restraint assessments were completed for the following dates and times. These assessments did not identify why the restraint was initiated, when the restraint was initiated, by whom, or what type of restraints were in use.
3/5/2021 at 1:20 PM
3/5/2021 at 5:28 PM
3/5/2021 at 7:00 PM
3/5/2021 at 9:00 PM
3/5/2021 at 11:00 PM
3/6/2021 at 1:00 AM
3/6/2021 at 3:00 AM
3/6/2021 at 5:00 AM
3/6/2021 at 7:00 AM
3/6/2021 at 9:00 AM
3/6/2021 at 11:00 AM



Order 3/6/2021 at 1:44 PM "Restraint, Non-Violent/Medical. Wrists, Both Disrupting Medical/Surgical Treatment Climbing Out of Bed Line Removal Attempt"

The Assessment Nursing Restraint documented at 3:00 PM did not document the restraints being used. The assessment at 5:13 showed bilateral soft wrist restraints were in use. The nursing assessments beginning at 7:00 PM change of shift failed to document the restraints being used. On 3/7/2021 at the beginning of day shift at 7:15 AM, nursing staff document that soft wrist restraints were being used per the physician order for the initial assessment.

On 3/7/2021 at 9:00 AM the nurse noted that the restraints were removed for therapy. At 11:00 AM the nurse documented that the restraints were removed because the patient was sleeping. At 1:00 PM the nurse documented that the restraints remained off since 9:00 AM and the patient was calm.

On 3/7/2021 at 5:00 PM the nurse documented that the patient was placed in 4-point restraints (wrists and ankles tied to the bed) and all 4 side rails were raised to prevent the patient from exiting the bed. An order was not entered into the chart until 6:09 PM and did not include the use of all 4 bed rails to prevent the patient from exiting the bed.

Order 3/7/2021 at 6:09 PM "Restraint, Non-Violent/Medical. Wrists, Both Ankles, Both Disrupting Medical/Surgical Treatment Harm to Self Line Removal Attempt"

The Assessment Nursing Restraint documentation showed that all 4 bed rails were in use at 9:00 PM


Review of Patient #7

Patient #7 had been admitted after an intentional overdose of medications. Patient #7 also had a minimally displaced fracture of the right ankle as identified by X-Ray report from the afternoon of 3/4/2021. No documentation of the type of splint being used was found. No orders were found for the nursing care/precautions required for the fractured ankle and/or splint. Nursing notes from 3/4/2021 documented:

1:30 PM "Patient anxious and agitated. Patient removing oximetry monitor and BP cuff. Pateint instructed to leave devices in place and their importance. Patient states " they hurt, I feel horrible." Pt requiring frequent reminders and is unable to meet learning" (sic)

8:36 PM "Patient became very anxious and aggressive trying to get out of the bed, patient pulled off nasal cannula, attempted to pull off iv, started screaming and yelling. After failed redirection attempts Soft wrist restraints applied, sitter remains at bedside. Will continue to monitor."

Physician orders documented on 3/4/2021: 8:30 PM "Non-violent Medical Wrists - Disrupting Medical /Surgical Treatment Harm to Self Line Removal Attempt"

Nursing notes from 3/4/2021 documented: 11:41 PM "Patient became very aggressive yelling kicking screaming after asking for a bed pan. Writer went to assist with toileting and hygiene. Patient kicked writer. At this time decision was made to apply soft restraints to both ankles. Also received PRN order for Haldol IM. Meds given and patient cleaned as well as bed linen and gown changed. Vital signs stable. Will continue to monitor."



Review of physician orders from the timeframe of the behavioral emergency when the patient became a danger to staff showed that no order for bilateral ankle restraints was obtained for the Violent/Behavioral Restraint that was used. When the nurse completed patient care that placed her in proximity of being kicked by the patient, the ankle restraints were not removed. The Nursing Assessment Restraints section of the medical record showed that the patient remained tied to the bed by her wrists and ankles without a physician order for ankle restraints on:

3/4/2021 at 11:00 PM with no documented reasons for the ankle restraints applied or documentation of who actually applied the restraints;

3/5/2021 at 1:00 AM for the documented violent/behavioral reason that the patient was a "Harm to Others, Harm to Self" as well as the non-violent/medical reason that the patient attempted to remove lines and had no safety awareness.

3/5/2021 at 3:00 AM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 5:00 AM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 7:00 AM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 9:00 AM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 11:00 AM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 1:00 PM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 2:27 PM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 4:00 PM for the reasons "Harm to Self, Line Removal
Attempt"

3/5/2021 at 7:00 PM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 9:00 PM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/5/2021 at 11:00 PM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/6/2021 at 1:00 AM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/6/2021 at 3:00 AM for the reasons "Climbing Out of Bed, Harm to Others, Harm to Self, Line Removal Attempt, No Safety Awareness"

3/6/2021 at 7:00 AM the nurse charted in the Assessment Nursing Restraints, "restraints off at this time, sitter at bedside"

Restraints remained off until 3/6/2021 at 7:00 PM, the Assessment Nursing Restraints was documented that soft wrist restraints were in use and all 4 bedrails were being used as a restraint. A physician order had been entered on 3/6/2021 at 6:00 AM for "Restraint, nonviolent/medical wrists, both bed rails x 4 - Disrupting Medical /Surgical Treatment Harm to Self Line Removal Attempt". However, that order ended at 7:00 AM when the nurse removed the patient from restraints. No new order was obtained at 7:00 PM for restraints. The chart did not reflect what had happened at 7:00 PM that changed from the patient remaining restraint free the previous 12 hours to suddenly requiring restraints be placed again.


The patient record reflected the patient remained in restraints without a physician order at:

3/6/2021 at 7:00 PM, 8:00 PM, 11:00 PM

3/7/2021 at 1:00 AM, 3:00 AM, 5:00 AM

The next documentation of restraints in the Assessment Nursing Restraint section of the chart was on 3/7/2021 at 9:00 PM showing that the patient was in wrist restraints and ankle restraints. No documented reason for the patient being in restraints was found. No documentation was found of who initiated the restraints.

An order had been placed on 3/7/2021 at 09:21 AM for "Restraint, Non-Violent/Medical. Four Point Bed Rails x 4 Disrupting Medical/Surgical Treatment Harm to Self Line Removal Attempt". There was no associated assessment found at the time of the restraint order to show that the patient needed to be placed in restraints at 9:21 AM. There was no record that restraints had been used between 9:21 AM and 9:00 PM making the 9:21 AM order no longer valid. A new order should have been obtained at the time restraints became necessary at 9:00 PM. No documentation was found to show that was done.


Patient #7 remained tied to the bed by her wrists and ankles without a valid physician order for:

3/7/2021 at 9:00 PM with no documented reason for restraints

3/7/2021 at 11:00 PM with no documented reason for restraints

On 3/8/2021 at 1:00 AM and 3:00 AM the nurse documented "Restraint NB every 2 hr interventions" and "Restraints Assess/Monitor" but did not document the type of restraints in use or the reason they were applied. At 5:00 AM the nurse documented that both wrist and ankle restraints were still being used. No reason for use was documented.

3/8/2021 at 5:00 AM was the last documented use of restraints in the Assessment Nursing Restraint section of the chart. Review of the Physical Therapy Progress Note for 3/8/2021 at 3:50 PM documented, "Pt was supine in bed, 4 point restraints donned, and sitter at bedside. Pt has c/o slight pain but did not specify location. Pt NWB on RLE. Pt agreeable to therapy. PT Duration: 2:59-3:35 pm" and "Pt tolerated session well. pt's mobility is improving. Pt left in supine with call light and needs in reach, restraints intact, RN at sitter at bedside. Pt has potential to improve with continued skilled therapy to address deficits."


Despite multiple changes in nursing staff between shifts, no record was found of nursing staff verifying the physician order for restraints at the beginning of the shift to ensure a valid order was in place.


Review of the policy titled Non-violent/Medical-Restraints-NS, policy number 66872.3, approval and effective date 10/16/2020 was made as follows:

"Procedures:

1) Initial Orders for Non-Violent Restraint/Medical

a) A RN may apply restraints prior to notifying the physician after conducting a comprehensive assessment and attempting the least restrictive interventions. The need for a restraint intervention may occur so quickly that an order cannot be obtained prior to the application of restraints. In this situation, the order must be obtained either during the application of the restraint, or immediately (within fifteen minutes) after the restraint has been applied.
...
a) v) The least restrictive, safe and effective method of restraint is to be used. The type and technique used must be the least restrictive intervention that will be effective to protect the patient or others from harm.

a) vi) Restraint use should be discontinued when there is no longer adequate and appropriate justification for continued use and before an order expires. The use of restraints must be discontinued as soon as possible based on an individualized patient assessment and re-evaluation. Temporary release for caring for a patient is okay (feeding, ROM [range of motion], toileting). A trial release is a PRN order and not permitted.

2) Renewal Orders

a) Requires an in-person evaluation by the physician and a new order for restraints each calendar day by the Physician."



32143

Review of the Policy and Procedure titled "Violent/Behavioral- Restraint and Seclusion-NS" Policy Number :66071.1 stated, "Purpose: To set forth the conditions for managing restraints and/or seclusion of an individual who evidences a Behavioral Emergency ("imminent danger to self or others") and for whom less restrictive interventions have been determined to be ineffective or when the prevention of dangerous behavior does not allow for the consideration or implementation of less restrictive measures.

...the use of less restrictive interventions to ensure individual and staff member safety is supported by this policy, training, and clinical practice.

2) Restraint or seclusion for a behavioral emergency requires a physician order. The use of any form of a restraint, seclusion, and/or emergency medications, may be necessary to ensure the immediate safety of an individual or others.

3) As applicable, upon admission, or as soon as possible thereafter, the patient and legally authorized representative (LAR) (if applicable) will be advised of the hospital's policy related to the use of restraint or seclusion for a behavioral emergency and notification of the designated person or LAR. Any form of restraint or seclusion may never be used as a punitive measure, never done for the convenience of the staff members, and must be discontinued at the earliest possible time. Staff members will ensure the individual's privacy and dignity by providing a safe, private, and secure environment as soon as possible following the initiation of any type of restraint or seclusion. Individuals will be released from restraint and/or seclusion as soon as the risk of imminent danger is resolved, and the individual is able to contract for safe behavior ..."


Review of the Policy and Procedure Non-Violent/Behavioral- Restraint and Seclusion-NS" Policy Number :66872.3 stated, "Non-Violent/Non-self destructive Behavior- Behavior related to a non-psychiatric medical condition or symptom that indicate the need for an intervention to protect the individual from harm

a) Restraints necessary for patient's well-being in order to facilitate effective treatment when less restrictive measures have been determined to be ineffective. An example includes measures taken to protect the patency of essential IV lines or tubes."


Review of Patient #1's chart revealed he was taken by ambulance to the Emergency Room (ER) on 2/16/21 at 16:35 (4:35PM). Review of the ER Physician Notes dated on 2/16/21 at 16:35 (4:35PM) stated, "Patient stated complaint PSYCH, Narrative of Presenting Problem 31 y/o M with a hx of schizophrenia presents to the ED from ____ Group home c/o aggressive behavior x 1 hour. Pt was being more combative than normal, so EMS was called. EMS states that the pt's father reported that the pt was drooling that is new for him. Pt's father states he would like the pt to be placed in a psychiatric facility, specifically _____ (State Hospital) Pt. denies any sx." (SIC).
Patient #1 was examined by the ER physician and medically cleared for discharge. Review of the Nurses Notes dated 2/16/21 at 20:16 (8:16PM) stated, "Called ____ (State Hospital) regarding patient. Spoke with ____ (hospital employee) and was told that patient would need a crisis screening and then put on the waiting list at this time. 20:17 (8:17PM) Called and spoke with Group home (phone number listed). They were unable to take patient back at this time due to his aggression towards other residents."


Review of the physician notes dated 2/17/21 at 06:38 (6:38AM) stated, "Patient was seen/examined after shift change. Patient remains without complaint. Patient remains on waitlist for placement and psych eval. Remains medically cleared."


Review of the ER Physician Notes dated 2/17/21 at 14:03 (2:03PM) stated, " ...After discussing the patients presentation and symptoms with the patient's father and recent group home it appears the patient has had significant change in his mental status and physical abilities as far as activities of daily living. I will admit him to the hospital for further workup including evaluation by neurology due to previous seizures and psychiatry for possible medication complications ... Final Diagnostic Impression Altered Mental Status, encephalopathy ... Admit decision time 2/17/21 14:04 (2:04PM)."


An interview was conducted with Patient #1's father on 3/19/21 at 5:45PM. The father stated Patient #1 was diagnosed with Asperger Syndrome with mental disorders. The father stated that Patient #1 was going to a day program to work for the last five years and was doing well on his medications and was living at home. Patient #1's father confirmed that Patient #1 had a childlike mentality and required supervision. The father stated Patient #1 started to have some intermittent behavioral out bursts "just out of the blue" and started to become aggressive. Patient #1 was admitted to the State Hospital and was there for 9 months. The father stated he was not allowed to see the Patient #1 because of Covid-19 restrictions at the state facility. The father was informed Patient #1 was going to a group home and found Patient #1 heavily sedated, drooling, in a wheel chair and confused. The father felt Patient #1 was over sedated. The father was also concerned that Patient #1 may have had some new neurological issues going on and needed to have an MRI. 911 was called and Patient #1 was taken to the ER.


According to ninds.nih.gov, "Asperger syndrome (AS) is a developmental disorder. It is an autism spectrum disorder (ASD), one of a distinct group of neurological conditions characterized by a greater or lesser degree of impairment in language and communication skills, as well as repetitive or restrictive patterns of thought and behavior. Other ASDs include: classic autism, Rett syndrome, childhood disintegrative disorder, and pervasive developmental disorder not otherwise specified (usually referred to as PDD-NOS). Unlike children with autism, children with AS retain their early language skills.

The most distinguishing symptom of AS is a child's obsessive interest in a single object or topic to the exclusion of any other. Children with AS want to know everything about their topic of interest and their conversations with others will be about little else. Their expertise, high level of vocabulary, and formal speech patterns make them seem like little professors. Other characteristics of AS include repetitive routines or rituals; peculiarities in speech and language; socially and emotionally inappropriate behavior and the inability to interact successfully with peers; problems with non-verbal communication; and clumsy and uncoordinated motor movements.

Children with AS are isolated because of their poor social skills and narrow interests. They may approach other people but make normal conversation impossible by inappropriate or eccentric behavior, or by wanting only to talk about their singular interest. Children with AS usually have a history of developmental delays in motor skills such as pedaling a bike, catching a ball, or climbing outdoor play equipment. They are often awkward and poorly coordinated with a walk that can appear either stilted or bouncy."


Review of the History and Physical dated 2/17/21 at 1512 (3:15PM) revealed Patient #1 was a 31-year-old male admitted to the facility on 2/17/21 for Encephalopathy. Patient #1 had the following past medical history documented, "1. Seizure disorder, 2. Bipolar Disorder, 3. Schizophrenia, 4. Asperger's, 5. Anxiety, and 6. Hypertension. Assessment and Plan: 1. Encephalopathy with normal CT. Will obtain a Depakote and lithium level and have consulted both _____ (Psychiatry) and _____ (Neurology). We will defer management of psychiatric medications to _____ (Psychiatrist). 2. Gastroesophageal reflux disease. We will continue Protonix. 3. Deep venous thrombosis prophylaxis with sequential compression devices. Code status: Full Code. It is my opinion, he will require 2+ midnight stay for encephalopathy."

According to ninds.nih.gov "Encephalopathy is a term for any diffuse disease of the brain that alters brain function or structure ... Depending on the type and severity of encephalopathy, common neurological symptoms are progressive loss of memory and cognitive ability, subtle personality changes, inability to concentrate, lethargy, and progressive loss of consciousness."


Review of patient #1's clinical notes dated 2/27/21 at 10:00 AM stated," patient noted to be with aggressive behavior and hitting staff. Patient throwing food and other objects at staff and spitting. Dr. ____ (Staff #31 Hospitalist) at the bedside and ordered restraints and Ativan 1 mg IV. Patient continues to be aggressive."

Review of the physician orders dated 2/27/21 at 9:43AM stated, "Lorazepam (Ativan) 1 MG = 0.5Ml intravenously once PRN Anxiety stat and then routine. Review of the MAR revealed there were "no occurrences charted". There was no documentation found on why the nurse did not administer the medication.

Review of the physician orders dated 2/27/21 at 10:47 AM stated, "Lorazepam (Ativan) 0.5 MG = 0.25 ml intravenously Q4H PRN Anxiety." Review of the Medication Administration Record (MAR) revealed the order was not documented as administered and was discontinued on 2/27/21 at 11:45 AM.

Review of the nursing clinical notes dated 2/27/21 at 11:45AM stated, "Dr. ____ (Staff #31 Hospitalist) called and informed that the patient was still very agitated and aggressive with staff." There was no documentation that Staff #11 RN had administered any p.o. (by mouth) medications, attempted any de-escalation techniques, requested a sitter, notified the family/ ask for assistance, offered comfort measures such as food, fluids, or toileting.


Review of the physician orders revealed 2 more restraints were ordered for the patient as follows:

1) Review of the physician orders dated 2/27/21 at 11:46 AM Ativan 2 mg= 1mL IV Q4hrs PRN anxiety." Review of the MAR revealed the order was not documented as administered.

2) Review of the physician orders dated 2/27/21 at 10:46 AM stated, "Restraint Non-Violent/Medical Wrists, Both Vest for disrupting medical/surgical treatment harm to others. The same order was shown to be discontinued on 2/27/21 at 10:46AM.


Patient #1 was documented as having behavioral outbursts and had no active medical/surgical treatments ordered except for Physical Therapy (PT). Patient #1 had an IV but no treatment or medications were ordered except for medications for controlling behaviors. These medications can be given Intramuscular or by mouth. Review of Policy and Procedure "Violent/Behavioral- Restraint and Seclusion-NS" Policy Number :66071.1, revealed Patient #1 met the criteria for a Violent/Behavioral Restraint but the physician ordered a Non-violent/Medical Restraint.


Review of the Physician follow up note written by Staff #31 Hospitalist dated 2/27/21 at 14:41 stated, "Unfortunate 31 year old male with psychiatric problems. He has become more awake during the weekend. Psychiatry has been following. Yesterday, the patient became agitated and was interrupting his care. Also swinging at the nurses. Psychiatry had the patient take Zyprexa 10mg IM. That did little to control his behavior. Today, he is resting quietly but has periods of agitation and interrupting his care becoming aggressive with nurses. PLAN:

1. We will start Ativan IV every 4 hours. Titrate to control agitation.

2. Non- behavioral restraints, so he does not interrupt treatment or climb out of bed.

3. Routine clozapine and Depakote."


There were no restraints ordered. The order written on 2/27/21 at 10:46AM had been discontinued at 10:46AM. There was no found documentation that the physician was aware the order had been discontinued.


Review of the assessment report dated 2/7/21 revealed Staff #9 LVN (Licensed Vocational Nurse) assessed and documented on Patient #1 at 18:50 (6:50PM). The nurse documented that the patient was "cooperative, impulsive. Actions: Reassurance, Frequent monitoring, Orient to person place and time, comfort measures, reduce environmental stimuli, Offered Nutrition and/ Hydration, offered hygiene and elimination, bed/body alarm. There was no documentation found that Patient #1 was in mechanical restraints or had been in restraints.


Review of Patient #1's clinical notes dated 3/7/21 at 3:00AM Staff #10 LVN documented, "Pt agitation continues to worsen combative, yelling, shaking bedrails, hitting, clawing, and grabbing. PCT went into room to turn off call light that had come on while Ativan was being drawn up. Pt grabbed PCT and would not let her go. Took three nurses to get pt to release PCT and 2 mg of Ativan was given. Restraints were pulled from supply locker and charge nurse initiated restraints at 3:30AM. Took 5 nurses to restrain pt to keep him from harming himself. Pt put in 4 point restraints due to wrist restraints not being adequate. Security was called due to 4 point still not being adequate and with the help of two security officers a Posey was also added to keep staff and pt safe."


Review of the Restraints Clinical Notes dated 3/7/21 at 2:30AM revealed Staff #22 RN documented non behavioral restraints were initiated at 2:30AM for violent behaviors. Under "Reason for NB restraint - Harm to others, Harm to self, no safety awareness." Bilateral soft restraints were placed on wrists and ankles. Patient #1 was also placed in a "belt."


Review of the restraints clinical notes dated 3/7/21 at 2:30AM Staff #22 RN documented the following:

"Order within last calendar day- yes

Medications Reviewed- yes

Skin Assessment Prior to Restraints - Mild Bruising (no documentation of where the bruising was found, size, coloration)

Orient/Redirect/Educate- Redirect attention, Request compliance (there was no documentation of what the nurse did to attempt to redirect. No education documentation found.)

Sensory interventions- Appropriate lighting, Appropriate Activity, Appropriate Noise, Removal of precipitating stimuli

Additional Less Restrictive Interventions- Nurses Station.

Restraints Assess/Monitor- Agitated. No safety awareness, Less restrictive alternatives ineffective, Respirations even and unlabored, Attempting to get out of bed."


Review of Patient #1's physician orders revealed there was no restraint order for this application of restraints. There was a conflict in the nurses notes of when the behavioral outbursts happened and when they were documented. Staff # 10 stated the incident was on 3/7/21 at 3:00AM and restraints were applied at 3:30AM. The RN documented the restraints were initiated at 2:30AM.


Review of the Patient #1's MAR revealed Patient #1 was administered Ativan 2mg IV at 3:00AM, Zyprexa 10mg IM and Benadryl 25 mg IV x 1 stat at 4:03AM. Review of the MAR revealed the drug was given by an LVN at 4:03AM. There was no nursing assessment at 4:00AM that described Patient #1's behavior at the time of drug administration to determine if the medication was still needed and required for a chemical restraint/ EBM. There was no found documentation on the effectiveness of the medication. There was no documentation after the initiation of restraints on how long Patient #1 was in restraints, if he was assessed in the restraints for safety, if the restraints were removed or continued.


Review of Patient #1's physician orders on 3/7/21 at 11:08AM stated, "Restraint, Non-Violent/Medical. Wrists, Both Ankles, Both Disrupting Medical/Surgical Treatment."


Review of Patient #1's chart revealed there was no found documentation of patient behaviors, assessment of the patient, or initiation of physical restraints.


Review of the physician progress notes dated 3/7/21 at 11:16AM stated, " ...not fit to be home or in a group home anymore, ended up requiring soft restraints from his belligerence. He is in need of a psychiatric hospital placement ..." The physician discussed the wrist restraints but not the use of PRN psychotropics and sedatives administered for the patient's aggressive behavior.


Review of the clinical notes dated 3/7/21 at 17:39 (5:39PM) revealed Staff #11 RN documented, "Patient noted to be combative and agitated. Currently with restraints at legs and arms and chest. Patient required to have a mask on as he is spitting at the staff. Verbally abusive and unpredictable with his aggression. Patient provided with a new IV 18g at the upper left arm. PRN medications provided to this patient as per MD orders with no noted improvement in his behavior. Patient continues to be very aggressive pulling." There was no documentation that Patient #1 was in restraints.


Review of Patient #1's chart revealed Staff #11 RN documented on 3/7/21 at 17:39 (5:39PM) that Patient #1 was currently in restraints. There was no found documentation of Patient #1 being placed in restraints. Staff #11 RN documented that Patient #1 "currently with restraints at legs and arms and chest." The physician restraint order on 3/7/21 at 11:08AM stated both wrists and both ankles but not a chest restraint. Staff #11 documented that Patient #1 was also placed in a mask due to his spitting with no physician order. Patient #1 was in 4 point restraints, a chest restraint and a mask.


According to the Policy and Procedure "Violent/Behavioral- Restraint and Seclusion-NS and Non-Violent/Behavioral- Restraint and Seclusion, a Violent/Behavioral Restraint was the appropriate restraint to order for Patient #1. Review of the Policy and Procedure "Violent/Behavioral- Restraint and Seclusion-NS and Non -Violent stated, "Prohibited Practices for Restraint or Seclusion in a Behavioral Emergency 6) Spit hoods, masks, or anything that covers and potentially obstructs an individual's airway ..."


Review of the clinical notes dated 3/7/21 at 18:52 (6:52PM) stated Patient noted to take off his restraints at this time. Patient currently not hitting staff but is noted to be unpredictable." There was no nursing documentation found for an ongoing assessment or effectiveness of the restraints application or how Patient #1 was able to get out of 4 point restraints, a chest restraint, and a mask on his own. If a patient is properly restrained, then the patient should not be able to remove the restraints on his/her own.


Review of Policy and Procedure "Violent/Behavioral- Restraint and Seclusion-NS" Policy Number :66071.1
Restraints (any type) or seclusion may be used only after less restrictive interventions have been considered or attempted and determined to be ineffective or are judged to be unlikely to protect the individual or others from harm in an emergent situation. The rationale for failure to utilize less restrictive measures must be documented. Examples of less restrictive measures may include, but are not limited to:

1) Asking the individual to stop the dangerous behavior and review treatment goals

2) Making a verbal/written contract for the desired safe behavior

3) Redirecting the individual's aggression by providing an activity to diffuse the agitation

4) Providing physical activity to help individual release anger or violent emotions

5) Providing 1:1 counseling to help individual identify causes of agitation or violent behavior

6) Introducing trauma-based strategies to allow for self- regulation

7) Allowing an individual an opportunity to call a support person or family member

8) Offering medications to assist the individual in regaining control

9) Offering food or beverage to the individual

10) Allowing the individual an appropriate outlet to reduce tension such as physical activity, music, sleep, deep breathing exercises, arts/crafts

11) Removal of stimuli that precipitated the violent/aggressive behavior

12) Reduction of noise and/or light levels

13) Suggesting a clinical time-out or allowing for a quiet time

14) Show of force

15) Elevating the Observation Status of the patient


Time Limits for Behavioral Restraint or Seclusion: 1) A physician may order a physical or mechanical restraint or seclusion in response to a behavioral emergency for a period of time not to exceed the following:

a) 15 minute maximum for physical hold on an individual of any age

b) 8 years=1 hour maximum

c) 9-17 years=2 hour maximum

d) >18 years=4 hour maximum.


Procedure for a Behavioral Restraint or Seclusion:

1) Initiating a Restraint or Seclusion:

a) "Security Alert: Staff Assistance Needed" is called wh