HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 10 (Pt. #1) patients' records reviewed with restriction of rights, the Hospital failed to inform patient of patient's right in advance of furnishing patient care for restraint application.

Findings include:

1. On 2/18/2020, the Hospital's policy titled, "Use of Restraints and Seclusion" (reviewed by the Hospital 9/15/2019) was reviewed and required, "A. Assessment and Care of patient in Restraints...7. For patients in the Emergency Department or on Behavioral Health, the staff informs patient, Guardian (if applicable) and any other designated person of restriction of rights and completes a 'Restriction of Rights' form."

2. On 2/18/2020, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 11/19/19 with a diagnosis of unspecified psychosis (mental illness).

-The Nursing progress note, dated 11/20/19 at 3:30 AM, included, "Pt. [Pt. #1] became combative and aggression throwing stuff in the room and put hole in the wall, very ready to fight, security was call [ed] and Pt. Pt. #1 was put in restrain [restraints]."
-The Physician's order, dated 11/20/19 at 3:15 AM, included an order for restraints.
-The clinical record lacked a "Restriction of Rights" form for the restraint application on 11/20/19 at 3:30 AM.

3. On 2/19/2020 at 9:36 AM, an interview was conducted with the Director of Behavioral Health Unit (E #4). E #4 stated that a Restriction of Rights form must be completed for each patient with each restraint application.

Based on document review and interview, it was determined that for 1 of 10 (Pt #3) patients' records reviewed, the Hospital failed to ensure that the use of restraints was in accordance with the written modification to the patient's plan of care.

Findings include:

1. On 2/18/20, the Hospital's policy titled, "Use of Restraints and Seclusion" (reviewed by the Hospital 9/15/2019) was reviewed and required, "...Plan of Care (POC) based on an assessment and evaluation of the patient... reflects the use of a Restraint or Seclusion intervention. Discontinuation of the Restraint should also be reflected in the POC...

2. On 2/18/20, Pt #3's clinical record was reviewed. Pt #3 was admitted on 2/12/2020 with the diagnosis of bipolar disorder (serious mental illness). Pt #3 was placed in restraints on 2/14/20. Pt #3's plan of care (undated) lacked the use of restraints.

3. On 2/18/20 at 11:15 AM, an interview was conducted with the Chief Clinical Officer (MD #1). MD #1 stated Pt #3's plan of care should have included the use of restraints.

Based on document review and interview, it was determined that for 1 of 10 (Pt #1) patients' records reviewed for restraint assessment, the Hospital failed to ensure that the condition of a restrained patient was monitored hourly by a Physician, Nurse, or trained staff.

Findings include:

1. On 2/18/2020, the Hospital's policy titled, "Use of Restraints and Seclusion" (reviewed by the Hospital 9/15/19) was reviewed. The policy included, "Restraint and Seclusion monitoring for Violent, self-destructive patients...Monitoring: A physician, APN [Advance Practice Nurse], or RN [Registered Nurse] competent pursuant to this policy, must monitor the patient at the initiation of Restraint of Seclusion and at a minimum every hour while the patient remains in restraints...The monitoring includes, as appropriate to the type of Restraint of Seclusion, the following: a. Signs of any injury associated with applying the Restraints or Seclusion. b. The patients's physical and emotional wellbeing, including hydration, hygiene, and elimination needs. c. Skin integrity d. Assessing vital signs, circulation. e. Mental status and neurological evaluations. f. That rights, dignity, and safety of the patient are maintained. g. Circulation and range of motion in the extremities. h. Physical and psychological status and comfort. i. Readiness for discontinuation of Restraint or Seclusion."

2. On 2/18/2020, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 11/19/19 with a diagnosis of unspecified psychosis (mental illness).
-The Physician's order, dated 11/19/19, included fall, seizure and assault precautions.
-The Physician's order, dated 11/20/19 at 3:15 AM, included a restraint order.
-The Nursing progress note, dated 11/20/19, indicated that Pt#7 was in restraints from 3:15 AM - 6:00 AM, and from 7:50 AM - 10:30 AM.
-The Physician's order, dated 11/21/19 at 2:45 PM, included a restraint order.
-The Nursing progress note, dated 11/21/19, indicated that Pt. #1 was in restraints from 2:45 PM - 5:20 PM.
-The clinical record lacked documentation of the hourly restraint assessments while Pt #1 was in restraints on 11/20/19 and 11/21/19 .

3. On 2/19/2020 at 9:36 AM, an interview was conducted with the Director of the Behavioral Health Unit (E #4). E #4 stated that the patient's condition and behavior must be assessed every 30 minutes to an hour, while in restraints.

Based on document review and interview, it was determined that for 1 of 10 (Pt. #1) patients' records reviewed for restraint documentation, the Hospital failed to complete a 1 hour face to face evaluation within one hour of placing a patient in restraints for violent and self-destructive behavior.

Findings include:

1. On 2/18/2020, the Hospital's policy titled, "Use of Restraints and Seclusion" (reviewed by the Hospital on 9/15/19) was reviewed and required, "A. Assessment and Care of Patient in Restraints...11. Within one (1) hour of restraint application , a face to face evaluation by a trained practitioner (MD [Medical Doctor], DO [Doctor of Osteopath], PA [Physician Assistant] or APN [Advanced Practice Nurse]) must be conducted and documented in patient medical record."

2. On 2/18/2020, Pt. #1's clinical record was reviewed. Pt. #1 was admitted on 11/19/19 with a diagnosis of unspecified psychosis (mental illness).
- The Physician order, dated 11/21/19 at 2:45 PM, included a restraint order.
- The Nursing progress note, dated 11/21/19, indicated that Pt. #1 was in restraints from 2:45 PM - 5:20 PM.
- The clinical record included a one hour face to face evaluation by a Licensed Indepent Practitioner dated 11/22/19 at 7:36 PM (29 hours 51 minutes after the application of restraints).

3. On 2/19/2020 at 9:36 AM, an interview was conducted with the Director of the Behavior Health Unit (E #4). E #4 stated that a one (1) hour face to face evaluation must be conducted for each patient within one hour of every application of restraints.