HospitalInspections.org

Based on medical record review, document review and interview, in three (3) of 12 medical records (MR) reviewed, it was determined the facility failed to ensure that the use of restraints was consistent with the physicians' orders and to follow its policy to document physicians' orders for the use of restraints. (Patients #s 1, 2, and 3).

Findings include:

The policy titled "Restraint and Seclusion-Behavioral Health Services," revised 4/2022 states, "An order for restraint is to be obtained prior to the application of any Restraint, except in emergency situations when the need for intervention may occur quickly and the Physician is not immediately available. In these emergency application situations, the order is to be obtained either during the application of Restraint or as soon as possible after the Restraint has been applied."

Review of MR for Patient #1 identified a 34-year-old patient who presented to the Emergency Department (ED) on 4/1/24 at 10:26 PM for suicidal ideation. The patient's previous history was significant for Schizoaffective Disorder, Obsessive Compulsive Disorder, Anxiety Disorder, Marijuana intoxication, and Hypothyroidism. A nurse documented the patient became agitated on 4/2/24 and four (4) point restraints were applied at 1:51 PM. The nurse also documented Five (5)-point restraints were applied at 2:18 PM until 5:00 PM that day.

The physician's restraint order 4/2/24 at 1:52 PM noted "Restraint Initiate Violent 18 years or older. Duration 4 hours, 4-point extremity, less restrictive alternatives failed."

There was no documentation in the medical record of a physician's order for the five (5) point restraints that were applied on 4/2/24 2:18 PM.


Review of MR for Patient #2 identified a 23-year-old patient presented to the ED on 4/15/24 and was triaged at 4:31 PM with a complaint of erratic behavior. The patient presented in handcuffs with police. The patient's previous medical history was significant for Autism, Seizure Disorder and Mental Health Disorder.

The physician's restraint order 4/15/24 at 6:20 PM noted "Restraint Initiate Violent 18 years or older. Duration 4 hours, 4-point extremity, less restrictive alternatives failed."

Nursing documentation indicate that four (4) point restraints were applied at 6:20 PM on 4/15/24 when the patient's safety became an issue, and the patient became violent and was acting out towards ED staff. On 4/15/24 at 6:28 PM, a nurse documented "patient placed in 5th point for safety." The nurse documented the restraints were removed at 7:15 PM that day.

There was no physician order for the five (5) point restraints.


Review of MR for patient #3 identified a 41-year-old patient presented to the ED in handcuffs on 2/29/24 and the nurse triaged the patient at 5:40 PM. At that time the patient was combative and with paranoid delusions and stating that police are after him. The patient's previous medical history included Unspecified Schizophreniform Disorder.

The physician's restraint order on 2/29/24 at 5:39 PM noted, "Restraint Initiate Violent 18 years or older. Duration 4 hours, 4-point extremity, less restrictive alternatives failed."

On 2/29/24, a nurse documented on the flow sheet, the patient was in five (5) point restraints from 5:30 PM to 7:50 PM. At 7:04 PM, the nurse documented, "patient was restrained upon arrival due to paranoid delusions and aggressive behavior towards staff and not responsive to any de-escalation attempts. The patient began to scream profanities at staff and was uncooperative with lab work and EKG. Patient remains in restraints."

The ED doctor documented at 5:40 PM that the patient was in ankle and wrist restraints.

There was no documentation in the order forms for the five (5) point restraints.

These findings were shared with Staff A, Regional Director, Quality and Safety Northern Region during an interview conducted on 5/31/24 at 3:45 PM.

Based on medical record review, document review and interview, in one (1) of 12 medical records (MR) reviewed, it was determined the nursing staff failed to notify a provider that the patient was placed in five (5) point restraints. (Patient #2).


Findings include:

The policy titled "Restraint and Seclusion-Behavioral Health Services," revised 4/2022 states, "An order for restraint is to be obtained prior to the application of any Restraint, except in emergency situations when the need for intervention may occur quickly and the Physician is not immediately available. In these emergency application situations, the order is to be obtained either during the application of Restraint or as soon as possible after the Restraint has been applied."

Review of the MR for Patient#2 identified a 23-year-old patient presented to the Emergency Department (ED) on 4/15/24 and was triaged at 4:31 PM with a complaint of erratic behavior. The patient presented in handcuffs and was accompanied with police. The patient's previous medical history was significant for Autism, Seizure Disorder and Mental Health Disorder.

A doctor documented at 6:20 PM on 4/15/24 a restraint order for "Restraint Initiate Violent 18 years or older. Duration 4 hours, 4-point extremity, less restrictive alternatives failed."

Nursing documentation indicate that four (4) point restraints were applied at 6:20 PM on 4/15/24 when the patient safety became an issue, and the patient became violent and was acting out towards the ED staff. A nurse also documented on 4/15/24 at 6:28 PM the "patient placed in 5th point for safety."
The nurse documented the restraints were removed at 7:15 PM that day.

There was no documentation in the medical record that a nurse informed a provider the patient was placed in five (5) point restraints on 4/15/24 and there was no documentation in the medical record of the time the five (5) point restraints were applied or removed.

These findings were shared with Staff A, Regional Director, Quality and Safety Northern Region during an interview conducted on 5/31/24 at 3:55 PM.